MEDICARE: THE SHEKINAH TRIAD PC

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	149008999	IL

General Provider Information

NPI Number	:	1417026022
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE SHEKINAH TRIAD PC

Provider Business Mailing Address
First Line	:	2016 N KENNICOTT
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-2922
Country	:	US
Telephone Number	:	847-220-1331
Fax Number	:	847-398-3099

Provider Business Practice Location Address
First Line	:	2016 N KENNICOTT
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-2922
Country	:	US
Telephone Number	:	847-220-1331
Fax Number	:	847-398-3099

Authorized Official
Title or Position	:	PRESIDENT CLINICAL DIRECTOR
Name	:	MS. MARILYN JOANNE NADULEK
Credential	:
Telephone Number	:	847-220-1331

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	10/06/2010

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