MEDICARE: MS. MARY LOU PETTY MSW 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		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0005983663	OTHER		AETNA
2	190629	OTHER		VALUE OPTIONS
3	5906676720	OTHER		UNITED BEHAVIORAL HEALTH
4	01673624	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1598747461
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY LOU PETTY MSW LCSW

Provider Business Mailing Address
First Line	:	30 N MICHIGAN AVE
Second Line	:	STE 1004
City	:	CHICAGO
State	:	IL
Zip	:	60602-3402
Country	:	US
Telephone Number	:	312-236-4364
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 N MICHIGAN AVE
Second Line	:	STE 1004
City	:	CHICAGO
State	:	IL
Zip	:	60602-3402
Country	:	US
Telephone Number	:	312-236-4364
Fax Number	:

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

Provider Enumeration Date	:	11/16/2005
Last Update Date	:	07/08/2007

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