MEDICARE: MS. TARA EVELLE CAMERON LCSW

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	149.009118	IL

General Provider Information

NPI Number	:	1902130529
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TARA EVELLE CAMERON LCSW

Provider Business Mailing Address
First Line	:	6575 N GLENWOOD AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-5175
Country	:	US
Telephone Number	:	773-218-2181
Fax Number	:

Provider Business Practice Location Address
First Line	:	5445 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1220
Country	:	US
Telephone Number	:	773-728-5106
Fax Number	:

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

Provider Enumeration Date	:	09/29/2009
Last Update Date	:	09/29/2009

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