=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922728146
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY CATHERINE SANTOS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2022
-----------------------------------------------------
Last Update Date | 08/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2211B LAKESIDE DR
-----------------------------------------------------
City | BANNOCKBURN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-1265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-217-9381
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1910 N MOZART ST APT 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-7070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-420-3815
-----------------------------------------------------
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 | TBD
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------