MEDICARE: THOMAS UNDINE

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	149.013059	IL

General Provider Information

NPI Number	:	1366823585
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THOMAS UNDINE

Provider Business Mailing Address
First Line	:	410 S MICHIGAN AVE STE 943
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60605-1399
Country	:	US
Telephone Number	:	773-732-7700
Fax Number	:	773-304-3517

Provider Business Practice Location Address
First Line	:	410 S MICHIGAN AVE STE 943
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60605-1399
Country	:	US
Telephone Number	:	773-732-7700
Fax Number	:	773-304-3517

Authorized Official
Title or Position	:	FOUNDING THERAPIST
Name	:	THOMAS R UNDINE
Credential	:	LCSW
Telephone Number	:	773-732-7700

Provider Enumeration Date	:	06/12/2015
Last Update Date	:	06/12/2015

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Directions to “THOMAS UNDINE ” Practice Location

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