MEDICARE: MRS. TARA TOLAND SR. 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	149.005474	IL
2	222Q00000X	Developmental Therapist	TT20360603P	IL

General Provider Information

NPI Number	:	1457577215
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TARA TOLAND SR. LCSW

Provider Business Mailing Address
First Line	:	4138 N RICHMOND ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-2614
Country	:	US
Telephone Number	:	773-583-7604
Fax Number	:

Provider Business Practice Location Address
First Line	:	4138 N RICHMOND ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-2614
Country	:	US
Telephone Number	:	773-583-7604
Fax Number	:

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

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	06/30/2009

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