MEDICARE: LAVONZELL MOSES-SCOTT

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	149010746	IL

General Provider Information

NPI Number	:	1699245530
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAVONZELL MOSES-SCOTT

Provider Business Mailing Address
First Line	:	3331 W POLK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60624-4148
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3331 W POLK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60624-4148
Country	:	US
Telephone Number	:	312-914-2483
Fax Number	:

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

Provider Enumeration Date	:	12/04/2018
Last Update Date	:	12/04/2018

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Directions to “ LAVONZELL MOSES-SCOTT ” Practice Location

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