MEDICARE: CAMDEN KRUSEC 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	149.024828	IL

General Provider Information

NPI Number	:	1679280309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAMDEN KRUSEC LCSW

Provider Business Mailing Address
First Line	:	1701 N ALBANY AVE APT 1F
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-7490
Country	:	US
Telephone Number	:	616-648-5216
Fax Number	:

Provider Business Practice Location Address
First Line	:	1607 W HOWARD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-1675
Country	:	US
Telephone Number	:	773-508-6100
Fax Number	:

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

Provider Enumeration Date	:	11/02/2022
Last Update Date	:	11/02/2022

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