MEDICARE: OLIVIA NDYABAGYE 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

General Provider Information

NPI Number	:	1710550405
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVIA NDYABAGYE LCSW

Provider Business Mailing Address
First Line	:	6600 S COTTAGE GROVE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60637-4127
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6600 S COTTAGE GROVE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60637-4127
Country	:	US
Telephone Number	:	773-207-0588
Fax Number	:

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

Provider Enumeration Date	:	07/20/2021
Last Update Date	:	07/20/2021

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