MEDICARE: MS. AYESHA OLLIE LSW

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	104100000X	Social Worker	150.012014	IL

General Provider Information

NPI Number	:	1942666003
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AYESHA OLLIE LSW

Provider Business Mailing Address
First Line	:	407 E 50TH PL
Second Line	:	73
City	:	CHICAGO
State	:	IL
Zip	:	60615-2328
Country	:	US
Telephone Number	:	773-629-5048
Fax Number	:

Provider Business Practice Location Address
First Line	:	407 E 50TH PL
Second Line	:	73
City	:	CHICAGO
State	:	IL
Zip	:	60615-2328
Country	:	US
Telephone Number	:	773-629-5048
Fax Number	:

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

Provider Enumeration Date	:	01/05/2016
Last Update Date	:	01/05/2016

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