MEDICARE: JULIE BERESNY DONAHOE 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	149.013584	IL

General Provider Information

NPI Number	:	1356628440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIE BERESNY DONAHOE LCSW

Provider Business Mailing Address
First Line	:	4659 N RAVENSWOOD AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-7212
Country	:	US
Telephone Number	:	773-435-6740
Fax Number	:	773-435-6740

Provider Business Practice Location Address
First Line	:	4659 N RAVENSWOOD AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-7212
Country	:	US
Telephone Number	:	773-435-6740
Fax Number	:	773-435-6740

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

Provider Enumeration Date	:	11/03/2011
Last Update Date	:	11/03/2011

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