MEDICARE: MS. MARY A LEE MACCCSLPL

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	235Z00000X	Speech-Language Pathologist	146.005733	IL

General Provider Information

NPI Number	:	1699979583
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY A LEE MACCCSLPL

Provider Business Mailing Address
First Line	:	3447 N SEELEY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-6113
Country	:	US
Telephone Number	:	773-550-6987
Fax Number	:	773-244-1364

Provider Business Practice Location Address
First Line	:	1640 N WELLS ST UNIT 103
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-6006
Country	:	US
Telephone Number	:	773-550-6987
Fax Number	:	773-244-1364

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

Provider Enumeration Date	:	06/13/2007
Last Update Date	:	03/22/2010

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