MEDICARE: CARRIE PODOLSKY 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	149015031	IL

General Provider Information

NPI Number	:	1790938561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARRIE PODOLSKY LCSW

Provider Business Mailing Address
First Line	:	840 S WAUKEGAN RD
Second Line	:
City	:	LAKE FOREST
State	:	IL
Zip	:	60045-2608
Country	:	US
Telephone Number	:	847-420-5088
Fax Number	:

Provider Business Practice Location Address
First Line	:	840 S WAUKEGAN RD
Second Line	:
City	:	LAKE FOREST
State	:	IL
Zip	:	60045-2608
Country	:	US
Telephone Number	:	847-420-5088
Fax Number	:

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

Provider Enumeration Date	:	10/24/2008
Last Update Date	:	10/21/2020

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