MEDICARE: MADELINE HAYNES MSW,LSW, 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	104100000X	Social Worker	150102599	IL
2	1041C0700X	Clinical Social Worker	149021923	IL

General Provider Information

NPI Number	:	1669074084
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADELINE HAYNES MSW,LSW, LCSW

Provider Business Mailing Address
First Line	:	1904 W CULLOM AVE APT 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-6713
Country	:	US
Telephone Number	:	847-899-1367
Fax Number	:

Provider Business Practice Location Address
First Line	:	1904 W CULLOM AVE APT 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-6713
Country	:	US
Telephone Number	:	847-899-1367
Fax Number	:

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

Provider Enumeration Date	:	11/10/2020
Last Update Date	:	11/10/2020

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