MEDICARE: PHYLLIS MANDLER L.C.S.W.

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		IL

General Provider Information

NPI Number	:	1356472708
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHYLLIS MANDLER L.C.S.W.

Provider Business Mailing Address
First Line	:	3750 N LAKE SHORE DR
Second Line	:	14E
City	:	CHICAGO
State	:	IL
Zip	:	60613-4238
Country	:	US
Telephone Number	:	773-281-6345
Fax Number	:	773-281-5526

Provider Business Practice Location Address
First Line	:	2502 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1850
Country	:	US
Telephone Number	:	773-281-6345
Fax Number	:	773-281-5526

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

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	07/08/2007

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Directions to “ PHYLLIS MANDLER L.C.S.W.” Practice Location

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