MEDICARE: TEGAN CHANEL BOLDEN

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	149022733	IL

General Provider Information

NPI Number	:	1538756804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TEGAN CHANEL BOLDEN

Provider Business Mailing Address
First Line	:	7305 S MICHIGAN AVE # 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-1618
Country	:	US
Telephone Number	:	773-494-4606
Fax Number	:

Provider Business Practice Location Address
First Line	:	7305 S MICHIGAN AVE # 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-1618
Country	:	US
Telephone Number	:	773-494-4606
Fax Number	:

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

Provider Enumeration Date	:	12/21/2020
Last Update Date	:	12/21/2020

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Directions to “ TEGAN CHANEL BOLDEN ” Practice Location

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