MEDICARE: MARISA IKENN LSW

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

General Provider Information

NPI Number	:	1073212320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISA IKENN LSW

Provider Business Mailing Address
First Line	:	9 CRYSTAL LAKE RD STE 140
Second Line	:
City	:	LAKE IN THE HILLS
State	:	IL
Zip	:	60156-1254
Country	:	US
Telephone Number	:	224-456-9356
Fax Number	:

Provider Business Practice Location Address
First Line	:	9 CRYSTAL LAKE RD STE 140
Second Line	:
City	:	LAKE IN THE HILLS
State	:	IL
Zip	:	60156-1254
Country	:	US
Telephone Number	:	224-456-9356
Fax Number	:

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

Provider Enumeration Date	:	02/27/2023
Last Update Date	:	02/27/2023

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