MEDICARE: MIA TERESA D'AGOSTINO 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	149-017535	IL

General Provider Information

NPI Number	:	1669953683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIA TERESA D'AGOSTINO LCSW

Provider Business Mailing Address
First Line	:	1526 W BELLE PLAINE AVE APT 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-1857
Country	:	US
Telephone Number	:	773-266-8984
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 W BRADLEY PL STE 210
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-4716
Country	:	US
Telephone Number	:	475-215-1234
Fax Number	:

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

Provider Enumeration Date	:	08/27/2018
Last Update Date	:	08/27/2018

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