MEDICARE: LISA SORCE SCHMITZ M.S.W, L.C.S.W.

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	101YM0800X	Mental Health Counselor		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01635825	OTHER	IL	BCBS OF IL PROVIDER #

General Provider Information

NPI Number	:	1740305093
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA SORCE SCHMITZ M.S.W, L.C.S.W.

Provider Business Mailing Address
First Line	:	2327 N 78TH AVE
Second Line	:
City	:	ELMWOOD PARK
State	:	IL
Zip	:	60707-3024
Country	:	US
Telephone Number	:	708-717-0758
Fax Number	:

Provider Business Practice Location Address
First Line	:	235 HARRISON ST
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60304-1533
Country	:	US
Telephone Number	:	708-717-0758
Fax Number	:

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

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	07/08/2007

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