MEDICARE: OLIVIA MANSOUR 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	104100000X	Social Worker	150.101890	IL
2	1041C0700X	Clinical Social Worker	149.020541	IL

General Provider Information

NPI Number	:	1285176354
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVIA MANSOUR LCSW

Provider Business Mailing Address
First Line	:	4800 N MILWAUKEE AVE STE 203
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-2156
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4800 N MILWAUKEE AVE STE 203
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-2156
Country	:	US
Telephone Number	:	312-379-9035
Fax Number	:

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

Provider Enumeration Date	:	11/07/2016
Last Update Date	:	07/02/2019

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