MEDICARE: MRS. ANDREA EVE WALLACH LCSW MSW

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	104100000X	Social Worker		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0001673683	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1033193545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANDREA EVE WALLACH LCSW MSW

Provider Business Mailing Address
First Line	:	208 CHARLES PL
Second Line	:
City	:	WILMETTE
State	:	IL
Zip	:	60091-3008
Country	:	US
Telephone Number	:	847-246-6426
Fax Number	:	847-256-6154

Provider Business Practice Location Address
First Line	:	115 S WILKE RD
Second Line	:	206 D
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60005-1532
Country	:	US
Telephone Number	:	847-256-6426
Fax Number	:	847-967-0929

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

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	07/08/2007

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