MEDICARE: NANCY PETERSON WALZ, LCSW, P.C.

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	149005637	IL

General Provider Information

NPI Number	:	1639436991
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NANCY PETERSON WALZ, LCSW, P.C.

Provider Business Mailing Address
First Line	:	PO BOX 742
Second Line	:
City	:	ISLAND LAKE
State	:	IL
Zip	:	60042-0742
Country	:	US
Telephone Number	:	815-382-7029
Fax Number	:

Provider Business Practice Location Address
First Line	:	7115 VIRGINIA RD
Second Line	:	SUITE 109
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-3112
Country	:	US
Telephone Number	:	815-382-7029
Fax Number	:	815-363-5584

Authorized Official
Title or Position	:	OWNER/ LICENSED CLINICAL SOCIAL WOR
Name	:	NANCY PETERSON WALZ
Credential	:	LCSW
Telephone Number	:	815-382-7029

Provider Enumeration Date	:	04/11/2012
Last Update Date	:	04/11/2012

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