=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871903443
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CONNIE RAYYAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2014
-----------------------------------------------------
Last Update Date | 05/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5730 W ROOSEVELT RD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60644-1580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-413-1700
-----------------------------------------------------
Fax | 773-413-1795
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5730 WEST ROOSEVELT ROAD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-413-1700
-----------------------------------------------------
Fax | 773-413-1795
-----------------------------------------------------
=====================================================
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 | 149.016486
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------