MEDICARE: LOURDES ROCHA LSW

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	104100000X	Social Worker	150102161	IL

General Provider Information

NPI Number	:	1497282701
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOURDES ROCHA LSW

Provider Business Mailing Address
First Line	:	4071 N BROADWAY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-2117
Country	:	US
Telephone Number	:	708-405-9409
Fax Number	:	872-231-2401

Provider Business Practice Location Address
First Line	:	4071 N BROADWAY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-2117
Country	:	US
Telephone Number	:	708-405-9409
Fax Number	:	872-231-2401

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

Provider Enumeration Date	:	05/17/2017
Last Update Date	:	11/05/2020

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