MEDICARE: ALISHA AGBONGHAE 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	1041C0700X	Clinical Social Worker	149.027711

General Provider Information

NPI Number	:	1073324026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALISHA AGBONGHAE LCSW

Provider Business Mailing Address
First Line	:	1074 W TAYLOR ST STE 383
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-4336
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1074 W TAYLOR ST STE 383
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-4336
Country	:	US
Telephone Number	:	312-590-7381
Fax Number	:

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

Provider Enumeration Date	:	01/17/2025
Last Update Date	:	01/17/2025

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