MEDICARE: MR. JOHN P HARRIS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01622421	OTHER	IL	BCBS
2	88423	OTHER	IL	MHN

General Provider Information

NPI Number	:	1629168661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN P HARRIS LCSW

Provider Business Mailing Address
First Line	:	1636 N WELLS #2901
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-6023
Country	:	US
Telephone Number	:	312-306-9503
Fax Number	:

Provider Business Practice Location Address
First Line	:	1636 N WELLS #2901
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-6023
Country	:	US
Telephone Number	:	312-306-9503
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	07/08/2007

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