MEDICARE: MS. CANDACE MARIE LEITHEISER 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	149017257	IL

General Provider Information

NPI Number	:	1154691988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CANDACE MARIE LEITHEISER LCSW

Provider Business Mailing Address
First Line	:	1200 N ASHLAND AVE
Second Line	:	SUITE 205
City	:	CHICAGO
State	:	IL
Zip	:	60622-2259
Country	:	US
Telephone Number	:	312-874-8198
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 N ASHLAND AVE
Second Line	:	SUITE 205
City	:	CHICAGO
State	:	IL
Zip	:	60622-2259
Country	:	US
Telephone Number	:	312-874-8198
Fax Number	:

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

Provider Enumeration Date	:	01/10/2012
Last Update Date	:	10/13/2015

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