MEDICARE: MS. TINA MARIE AUSTIN MSW

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	149011507	IL

General Provider Information

NPI Number	:	1174875785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TINA MARIE AUSTIN MSW

Provider Business Mailing Address
First Line	:	8153 S CHAMPLAIN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-5003
Country	:	US
Telephone Number	:	773-418-0795
Fax Number	:

Provider Business Practice Location Address
First Line	:	8153 S CHAMPLAIN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-5003
Country	:	US
Telephone Number	:	773-418-0795
Fax Number	:

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

Provider Enumeration Date	:	10/05/2012
Last Update Date	:	10/05/2012

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