MEDICARE: MR. DOUGLAS S LABELLE 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	6891123	WI
2	1041C0700X	Clinical Social Worker		IL

General Provider Information

NPI Number	:	1356475842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DOUGLAS S LABELLE LCSW

Provider Business Mailing Address
First Line	:	655 ROCKLAND RD
Second Line	:	STE. 103
City	:	LAKE BLUFF
State	:	IL
Zip	:	60044-1782
Country	:	US
Telephone Number	:	847-309-3781
Fax Number	:	847-482-1688

Provider Business Practice Location Address
First Line	:	655 ROCKLAND RD
Second Line	:	STE. 103
City	:	LAKE BLUFF
State	:	IL
Zip	:	60044-1782
Country	:	US
Telephone Number	:	847-309-3781
Fax Number	:	847-482-1688

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

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	01/16/2008

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