MEDICARE: DEBRA SUZANN PENTANGELO 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	149009061	IL

General Provider Information

NPI Number	:	1528309747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBRA SUZANN PENTANGELO LCSW

Provider Business Mailing Address
First Line	:	2957 N ALLEN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-6701
Country	:	US
Telephone Number	:	847-530-3949
Fax Number	:	312-408-5045

Provider Business Practice Location Address
First Line	:	3525 W PETERSON AVE
Second Line	:	T-17
City	:	CHICAGO
State	:	IL
Zip	:	60659-3324
Country	:	US
Telephone Number	:	847-530-3949
Fax Number	:

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

Provider Enumeration Date	:	03/13/2013
Last Update Date	:	03/13/2013

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