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NPI Code Detail

MEDICARE: MARIELLEN M. RE L.C.S.W./C.A.D.C.

MEDICARE: MARIELLEN M. RE L.C.S.W./C.A.D.C.
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
11041C0700XClinical Social WorkerIL

General Provider Information

NPI Number : 1669465340
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARIELLEN M. RE L.C.S.W./C.A.D.C.
Provider Business Mailing Address
First Line : 1303 W ALGONQUIN RD
Second Line :
City : LAKE IN THE HILLS
State : IL
Zip : 60156-3575
Country : US
Telephone Number : 847-854-8995
Fax Number : 847-658-0787
Provider Business Practice Location Address
First Line : 1303 W ALGONQUIN RD
Second Line :
City : LAKE IN THE HILLS
State : IL
Zip : 60156-3575
Country : US
Telephone Number : 847-854-8995
Fax Number : 847-658-0787
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/26/2005
Last Update Date : 07/08/2007

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