MEDICARE: MIRKA CAMILA GALLO 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	149024592	IL

General Provider Information

NPI Number	:	1164373536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRKA CAMILA GALLO LCSW

Provider Business Mailing Address
First Line	:	73 W MONROE ST STE 422
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60603-4955
Country	:	US
Telephone Number	:	888-500-2067
Fax Number	:	617-649-8520

Provider Business Practice Location Address
First Line	:	73 W MONROE ST STE 422
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60603-4955
Country	:	US
Telephone Number	:	888-500-2067
Fax Number	:	617-649-8520

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

Provider Enumeration Date	:	02/03/2026
Last Update Date	:	02/03/2026

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