MEDICARE: MR. LESLIE JOEL ILLIDGE

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	104100000X	Social Worker	150007727	IL

General Provider Information

NPI Number	:	1730763228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LESLIE JOEL ILLIDGE

Provider Business Mailing Address
First Line	:	8530 S SAINT LAWRENCE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-6025
Country	:	US
Telephone Number	:	773-852-0642
Fax Number	:

Provider Business Practice Location Address
First Line	:	8530 S SAINT LAWRENCE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-6025
Country	:	US
Telephone Number	:	773-852-0642
Fax Number	:

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

Provider Enumeration Date	:	05/10/2021
Last Update Date	:	05/10/2021

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