MEDICARE: CLEA ROSE MIRZA JAMES

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	106H00000X	Marriage & Family Therapist	208.000615	IL
2	106H00000X	Marriage & Family Therapist	166.001303	IL

General Provider Information

NPI Number	:	1821537978
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLEA ROSE MIRZA JAMES

Provider Business Mailing Address
First Line	:	5215 N RAVENSWOOD AVE STE 211
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1670
Country	:	US
Telephone Number	:	312-767-7855
Fax Number	:

Provider Business Practice Location Address
First Line	:	5215 N RAVENSWOOD AVE STE 211
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1670
Country	:	US
Telephone Number	:	312-767-7855
Fax Number	:

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

Provider Enumeration Date	:	02/21/2017
Last Update Date	:	07/01/2022

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