MEDICARE: MICHAEL MUDGETT 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	149.018688	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	383274841	OTHER		COMMERCIAL INSURANCE

General Provider Information

NPI Number	:	1134536865
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL MUDGETT LCSW

Provider Business Mailing Address
First Line	:	645 S CENTRAL AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60644-5059
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5524 W HARRISON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60644-5032
Country	:	US
Telephone Number	:	773-854-5073
Fax Number	:	773-379-0971

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

Provider Enumeration Date	:	07/15/2014
Last Update Date	:	01/31/2017

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