MEDICARE: MS. SELENE LEELAM MEHTA

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	149008544	IL

General Provider Information

NPI Number	:	1588938427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SELENE LEELAM MEHTA

Provider Business Mailing Address
First Line	:	628 N CHARTER HALL DR
Second Line	:
City	:	PALATINE
State	:	IL
Zip	:	60067-8678
Country	:	US
Telephone Number	:	847-212-9337
Fax Number	:

Provider Business Practice Location Address
First Line	:	721 S QUENTIN RD
Second Line	:
City	:	PALATINE
State	:	IL
Zip	:	60067-6778
Country	:	US
Telephone Number	:	847-359-7490
Fax Number	:	847-359-7525

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

Provider Enumeration Date	:	02/23/2012
Last Update Date	:	02/23/2012

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