MEDICARE: MS. HEATHER WITTHOFF 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	149010872	IL

General Provider Information

NPI Number	:	1619034238
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. HEATHER WITTHOFF MSW, LCSW

Provider Business Mailing Address
First Line	:	42W097 COPPERWOOD LN
Second Line	:
City	:	ST CHARLES
State	:	IL
Zip	:	60175-8236
Country	:	US
Telephone Number	:	773-387-4787
Fax Number	:

Provider Business Practice Location Address
First Line	:	1010 LAKE ST
Second Line	:	SUITE NUMBER 616
City	:	OAK PARK
State	:	IL
Zip	:	60301-1147
Country	:	US
Telephone Number	:	773-387-4787
Fax Number	:

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

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	06/04/2008

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