MEDICARE: IL LTC MHT

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

General Provider Information

NPI Number	:	1699547158
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IL LTC MHT

Provider Business Mailing Address
First Line	:	5454 FARGO AVE
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60077-3210
Country	:	US
Telephone Number	:	847-834-4923
Fax Number	:

Provider Business Practice Location Address
First Line	:	5454 FARGO AVE
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60077-3210
Country	:	US
Telephone Number	:	847-834-4923
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JAY GREENBERGER
Credential	:	CSW
Telephone Number	:	847-834-4923

Provider Enumeration Date	:	10/26/2023
Last Update Date	:	10/26/2023

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Directions to “IL LTC MHT ” Practice Location

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