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NPI Code Detail

MEDICARE: MRS. BENITA VIVIAN LACKAJS MSW, LCSW

MEDICARE: MRS. BENITA VIVIAN LACKAJS MSW, 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 : 1053406124
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. BENITA VIVIAN LACKAJS MSW, LCSW
Provider Business Mailing Address
First Line : 3249 N CENTRAL AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60634-4360
Country : US
Telephone Number : 773-371-3700
Fax Number : 773-282-6698
Provider Business Practice Location Address
First Line : 3249 N CENTRAL AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60634-4360
Country : US
Telephone Number : 773-371-3700
Fax Number : 773-282-6698
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/04/2006
Last Update Date : 04/04/2008

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