MEDICARE: MS. BARBARA STITT MISTELE 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	149001406	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04907177	OTHER	IL	BLUE CROSS PROVIDER NMBR

General Provider Information

NPI Number	:	1346312055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BARBARA STITT MISTELE LCSW

Provider Business Mailing Address
First Line	:	655 ROCKLAND RD
Second Line	:	SUITE 103
City	:	LAKE BLUFF
State	:	IL
Zip	:	60044-1782
Country	:	US
Telephone Number	:	847-986-3717
Fax Number	:

Provider Business Practice Location Address
First Line	:	655 ROCKLAND RD
Second Line	:	SUITE 103
City	:	LAKE BLUFF
State	:	IL
Zip	:	60044-1782
Country	:	US
Telephone Number	:	847-986-3717
Fax Number	:

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

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	07/08/2007

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