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NPI Code Detail

MEDICARE: MR. BRADLEY PHILIP SJOSTROM L.C.S.W.

MEDICARE: MR. BRADLEY PHILIP SJOSTROM 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 Worker149.008570IL

General Provider Information

NPI Number : 1467528521
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. BRADLEY PHILIP SJOSTROM L.C.S.W.
Provider Business Mailing Address
First Line : 938 W NELSON ST
Second Line :
City : CHICAGO
State : IL
Zip : 60657-6704
Country : US
Telephone Number : 773-296-5159
Fax Number : 773-296-3226
Provider Business Practice Location Address
First Line : 938 W NELSON ST
Second Line :
City : CHICAGO
State : IL
Zip : 60657-6704
Country : US
Telephone Number : 773-296-5159
Fax Number : 773-296-3226
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/28/2006
Last Update Date : 07/08/2007

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