MEDICARE: LAURA M. I. DZIEKIEWICZ 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	149015277	IL

General Provider Information

NPI Number	:	1508105826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA M. I. DZIEKIEWICZ LCSW

Provider Business Mailing Address
First Line	:	3713 N GREENVIEW AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-3609
Country	:	US
Telephone Number	:	773-542-3128
Fax Number	:	312-421-5889

Provider Business Practice Location Address
First Line	:	3713 N GREENVIEW AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-3609
Country	:	US
Telephone Number	:	773-542-3128
Fax Number	:	312-421-5889

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

Provider Enumeration Date	:	02/06/2013
Last Update Date	:	02/06/2013

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