=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376997379
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. SACHIKO KAWATA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2016
-----------------------------------------------------
Last Update Date | 06/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4753 N BROADWAY ST SUITE #925
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-5266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-989-2780
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4752 N BROADWAY ST #925
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-4909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-989-2780
-----------------------------------------------------
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 | 149.018432
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------