MEDICARE: SARA JOELLEN STUMPOS 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	149020275	IL

General Provider Information

NPI Number	:	1427613918
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARA JOELLEN STUMPOS LCSW

Provider Business Mailing Address
First Line	:	655 W IRVING PARK RD APT 3702
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-3116
Country	:	US
Telephone Number	:	517-862-0994
Fax Number	:

Provider Business Practice Location Address
First Line	:	1142 W MADISON ST UNIT 302
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-2191
Country	:	US
Telephone Number	:	517-862-0994
Fax Number	:

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

Provider Enumeration Date	:	05/09/2019
Last Update Date	:	05/09/2019

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