MEDICARE: MR. THOMAS JOSEPH WILDA SOCIAL WORK, MSW

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

General Provider Information

NPI Number	:	1629087994
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. THOMAS JOSEPH WILDA SOCIAL WORK, MSW

Provider Business Mailing Address
First Line	:	655 W IRVING PARK RD
Second Line	:	SUITE 202
City	:	CHICAGO
State	:	IL
Zip	:	60613-3123
Country	:	US
Telephone Number	:	773-528-8075
Fax Number	:	773-248-3638

Provider Business Practice Location Address
First Line	:	655 W IRVING PARK RD
Second Line	:	SUITE 202
City	:	CHICAGO
State	:	IL
Zip	:	60613-3123
Country	:	US
Telephone Number	:	773-528-8075
Fax Number	:	773-248-3638

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

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	07/08/2007

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