MEDICARE: MINDY DENISE STILLMAN LCSW, CCM

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	149-010227	IL

General Provider Information

NPI Number	:	1649722232
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MINDY DENISE STILLMAN LCSW, CCM

Provider Business Mailing Address
First Line	:	1636 W OLIVE AVE
Second Line	:	1N
City	:	CHICAGO
State	:	IL
Zip	:	60660-4123
Country	:	US
Telephone Number	:	847-778-0419
Fax Number	:

Provider Business Practice Location Address
First Line	:	1636 W OLIVE AVE
Second Line	:	1N
City	:	CHICAGO
State	:	IL
Zip	:	60660-4123
Country	:	US
Telephone Number	:	847-778-0419
Fax Number	:

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

Provider Enumeration Date	:	10/29/2016
Last Update Date	:	10/29/2016

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