MEDICARE: MS. DORIS W. KLINKHAMER 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		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01633160	OTHER	IL	BC/BS PPO PROVIDER NUMBER

General Provider Information

NPI Number	:	1386734671
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DORIS W. KLINKHAMER LCSW

Provider Business Mailing Address
First Line	:	4449 N CALIFORNIA AVE
Second Line	:	SECOND FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60625-3803
Country	:	US
Telephone Number	:	312-719-1926
Fax Number	:

Provider Business Practice Location Address
First Line	:	1165 N CLARK ST
Second Line	:	SUITE 413
City	:	CHICAGO
State	:	IL
Zip	:	60610-2702
Country	:	US
Telephone Number	:	312-719-1926
Fax Number	:

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

Provider Enumeration Date	:	10/15/2006
Last Update Date	:	07/08/2007

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