MEDICARE: AMY BLUE 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	149014168	IL

General Provider Information

NPI Number	:	1982321733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY BLUE LCSW

Provider Business Mailing Address
First Line	:	5952 W NEWPORT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-4222
Country	:	US
Telephone Number	:	708-374-7694
Fax Number	:

Provider Business Practice Location Address
First Line	:	5952 W NEWPORT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-4222
Country	:	US
Telephone Number	:	708-374-7694
Fax Number	:

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

Provider Enumeration Date	:	10/24/2022
Last Update Date	:	10/24/2022

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