=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104192145
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY MARION LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2012
-----------------------------------------------------
Last Update Date | 03/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1731 N MARCEY ST SUITE 535
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-5373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-280-1166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2337 N SPAULDING AVE 2ND FLOOR
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-2519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-859-1368
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 149014235
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------