MEDICARE: CHRISTOPHER J LACIVITA

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	235Z00000X	Speech-Language Pathologist	146004552	IL
2	235Z00000X	Speech-Language Pathologist	14004552	IL

General Provider Information

NPI Number	:	1134383037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTOPHER J LACIVITA

Provider Business Mailing Address
First Line	:	PO BOX 86
Second Line	:
City	:	WOODSTOCK
State	:	IL
Zip	:	60098-0086
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5536 W HENDERSON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-4135
Country	:	US
Telephone Number	:	815-690-6533
Fax Number	:

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

Provider Enumeration Date	:	07/10/2008
Last Update Date	:	07/10/2008

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Directions to “ CHRISTOPHER J LACIVITA ” Practice Location

Language	Start Address	Practice Location

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