MEDICARE: MS. AMY E BOARD LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	149.016736	IL

General Provider Information

NPI Number	:	1013395789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AMY E BOARD LCSW

Provider Business Mailing Address
First Line	:	700 N SACRAMENTO BLVD
Second Line	:	SUITE 201
City	:	CHICAGO
State	:	IL
Zip	:	60612-1046
Country	:	US
Telephone Number	:	773-916-4084
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 N SACRAMENTO BLVD
Second Line	:	SUITE 201
City	:	CHICAGO
State	:	IL
Zip	:	60612-1046
Country	:	US
Telephone Number	:	773-916-4084
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2015
Last Update Date	:	05/26/2020

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