MEDICARE: BRIAN VANDINE MSW

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	149008702	IL

General Provider Information

NPI Number	:	1750018016
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN VANDINE MSW

Provider Business Mailing Address
First Line	:	1893 COVE LN
Second Line	:
City	:	GLENDALE HTS
State	:	IL
Zip	:	60139-1920
Country	:	US
Telephone Number	:	630-665-8719
Fax Number	:	630-665-8719

Provider Business Practice Location Address
First Line	:	303 E WACKER DR STE 2102
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60601-5314
Country	:	US
Telephone Number	:	312-736-1776
Fax Number	:

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

Provider Enumeration Date	:	08/05/2022
Last Update Date	:	08/05/2022

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