MEDICARE: MS. FELICIA R. MADLOCK 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	149013410	IL

General Provider Information

NPI Number	:	1770818007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. FELICIA R. MADLOCK MSW

Provider Business Mailing Address
First Line	:	430 E 162ND ST # 109
Second Line	:
City	:	SOUTH HOLLAND
State	:	IL
Zip	:	60473-2258
Country	:	US
Telephone Number	:	773-369-6545
Fax Number	:	708-260-0466

Provider Business Practice Location Address
First Line	:	10336 S WESTERN AVE STE 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-2411
Country	:	US
Telephone Number	:	773-369-6545
Fax Number	:	708-260-0466

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

Provider Enumeration Date	:	10/05/2009
Last Update Date	:	03/19/2012

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