MEDICARE: ELLEN TANNENBAUM 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	149.012695	IL

General Provider Information

NPI Number	:	1184040032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN TANNENBAUM LCSW

Provider Business Mailing Address
First Line	:	2310 W ROOSEVELT RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-1131
Country	:	US
Telephone Number	:	312-655-7991
Fax Number	:	312-236-5384

Provider Business Practice Location Address
First Line	:	2310 W ROOSEVELT RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-1131
Country	:	US
Telephone Number	:	312-655-7991
Fax Number	:	312-236-5384

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

Provider Enumeration Date	:	03/14/2014
Last Update Date	:	08/12/2015

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