MEDICARE: MRS. ANGELA DENISE COLVILLE 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
1	101YP2500X	Professional Counselor	149013723	IL

General Provider Information

NPI Number	:	1063782423
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANGELA DENISE COLVILLE MSW, LCSW

Provider Business Mailing Address
First Line	:	1739 N WILMOT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5523
Country	:	US
Telephone Number	:	773-269-9400
Fax Number	:	269-912-5925

Provider Business Practice Location Address
First Line	:	1739 N WILMOT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5523
Country	:	US
Telephone Number	:	773-269-9400
Fax Number	:	269-912-5925

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

Provider Enumeration Date	:	01/03/2012
Last Update Date	:	10/24/2013

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