=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306431929
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELANIE GARRETT L GARRETT LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2021
-----------------------------------------------------
Last Update Date | 03/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5317 W CHICAGO AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60651-2815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-413-3470
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1106 N MOZART ST # 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60622-2718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-315-5562
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 149010556
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------