MEDICARE: BENJAMIN GRAY HAGAMAN 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	150.114643	IL

General Provider Information

NPI Number	:	1861207276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN GRAY HAGAMAN LSW

Provider Business Mailing Address
First Line	:	739 W MELROSE ST APT 2F
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-3462
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5537 N CLARK ST # B-1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-0751
Country	:	US
Telephone Number	:	312-675-4424
Fax Number	:

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

Provider Enumeration Date	:	02/12/2025
Last Update Date	:	02/12/2025

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