MEDICARE: MRS. GELA ALTMAN M.S.W.

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	149002602	IL
2	106H00000X	Marriage & Family Therapist	166000331	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1632478	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1447268628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GELA ALTMAN M.S.W.

Provider Business Mailing Address
First Line	:	5225 OLD ORCHARD RD
Second Line	:	SUITE 1-2
City	:	SKOKIE
State	:	IL
Zip	:	60077-4405
Country	:	US
Telephone Number	:	847-710-8106
Fax Number	:

Provider Business Practice Location Address
First Line	:	5225 OLD ORCHARD RD
Second Line	:	SUITE 1-2
City	:	SKOKIE
State	:	IL
Zip	:	60077-4405
Country	:	US
Telephone Number	:	847-710-8106
Fax Number	:

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

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	01/25/2013

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