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NPI Code Detail

MEDICARE: LAURA A LICEA LCSW

MEDICARE: LAURA A LICEA 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
11041C0700XClinical Social WorkerIL

General Provider Information

NPI Number : 1023142494
Entity Type Code : Individual
Provider Name (Legal Business Name) : LAURA A LICEA LCSW
Provider Business Mailing Address
First Line : 5359 W FULLERTON AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60639-1450
Country : US
Telephone Number : 708-836-2785
Fax Number : 773-836-7381
Provider Business Practice Location Address
First Line : 5359 W FULLERTON AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60639-1450
Country : US
Telephone Number : 708-836-2785
Fax Number : 773-836-7381
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/15/2007
Last Update Date : 07/09/2007

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Directions to “ LAURA A LICEA LCSW” Practice Location

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