MEDICARE: STORM DADE

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1194316927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STORM DADE

Provider Business Mailing Address
First Line	:	4137 OAKWOOD LN
Second Line	:
City	:	MATTESON
State	:	IL
Zip	:	60443-1920
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2023 RIDGE RD UNIT 2NW
Second Line	:
City	:	HOMEWOOD
State	:	IL
Zip	:	60430-1786
Country	:	US
Telephone Number	:	708-580-6042
Fax Number	:

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

Provider Enumeration Date	:	02/03/2021
Last Update Date	:	02/03/2021

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Directions to “ STORM DADE ” Practice Location

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