MEDICARE: WINIFRED ROSE LANDON LSW

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	150.104588	IL

General Provider Information

NPI Number	:	1801463310
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WINIFRED ROSE LANDON LSW

Provider Business Mailing Address
First Line	:	2353 W 18TH PL APT 3R
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-2560
Country	:	US
Telephone Number	:	630-779-0767
Fax Number	:

Provider Business Practice Location Address
First Line	:	2045 W NORTH AVE STE 2A
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5413
Country	:	US
Telephone Number	:	773-340-0203
Fax Number	:

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

Provider Enumeration Date	:	06/04/2021
Last Update Date	:	06/04/2021

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