MEDICARE: SHEILA N NISSIM L.C.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		IL

General Provider Information

NPI Number	:	1457418436
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHEILA N NISSIM L.C.S.W.

Provider Business Mailing Address
First Line	:	1431 W GRANVILLE AVE
Second Line	:	#3
City	:	CHICAGO
State	:	IL
Zip	:	60660-1809
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3166 N LINCOLN AVE
Second Line	:	#214A
City	:	CHICAGO
State	:	IL
Zip	:	60657-3133
Country	:	US
Telephone Number	:	773-209-5788
Fax Number	:

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

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	07/08/2007

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