MEDICARE: THOMAS S DOCTOR LCSW, CADC

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	149020386	IL

General Provider Information

NPI Number	:	1871847483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS S DOCTOR LCSW, CADC

Provider Business Mailing Address
First Line	:	2650 W MONTROSE AVE STE 102
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-1562
Country	:	US
Telephone Number	:	773-377-5261
Fax Number	:

Provider Business Practice Location Address
First Line	:	2650 W MONTROSE AVE STE 102
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-1562
Country	:	US
Telephone Number	:	773-377-5261
Fax Number	:

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

Provider Enumeration Date	:	11/04/2012
Last Update Date	:	01/03/2024

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