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NPI Code Detail

MEDICARE: MR. ROBERT EDWARD MANRIQUE L.C.S.W.

MEDICARE: MR. ROBERT EDWARD MANRIQUE 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
11041C0700XClinical Social Worker149.012855IL

General Provider Information

NPI Number : 1457639437
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. ROBERT EDWARD MANRIQUE L.C.S.W.
Provider Business Mailing Address
First Line : 5415 N SHERIDAN RD
Second Line : 1514
City : CHICAGO
State : IL
Zip : 60640-1954
Country : US
Telephone Number : 312-218-5293
Fax Number :
Provider Business Practice Location Address
First Line : 5419 N SHERIDAN RD
Second Line : SUITE 103A
City : CHICAGO
State : IL
Zip : 60640-1964
Country : US
Telephone Number : 312-944-0760
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/25/2011
Last Update Date : 04/06/2012

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