=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083925762
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VERONICA TSU LICKFELT LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2010
-----------------------------------------------------
Last Update Date | 06/28/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 E JACKSON ST FL 2
-----------------------------------------------------
City | OSWEGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60543-8696
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-315-7045
-----------------------------------------------------
Fax | 630-551-2213
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 705 N SPARKLE CT
-----------------------------------------------------
City | OSWEGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60543-7942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-315-7045
-----------------------------------------------------
Fax | 630-551-2213
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149014218
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------