MEDICARE: COLVILLE COUNSELING, LLC

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	149013723	IL

General Provider Information

NPI Number	:	1891124210
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLVILLE COUNSELING, LLC

Provider Business Mailing Address
First Line	:	1739 N WILMOT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5523
Country	:	US
Telephone Number	:	773-269-9400
Fax Number	:

Provider Business Practice Location Address
First Line	:	1739 N WILMOT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5523
Country	:	US
Telephone Number	:	773-269-9400
Fax Number	:

Authorized Official
Title or Position	:	LICENSED CLINICAL SOCIAL WORKER
Name	:	MRS. ANGELA DENISE COLVILLE
Credential	:	LCSW
Telephone Number	:	773-269-9400

Provider Enumeration Date	:	11/06/2013
Last Update Date	:	11/06/2013

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