MEDICARE: MS. MELISSA AMY MANKOFF LCSW, 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	149.014466	IL

General Provider Information

NPI Number	:	1942573175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MELISSA AMY MANKOFF LCSW, LLC

Provider Business Mailing Address
First Line	:	1636 N WELLS ST
Second Line	:	#1807
City	:	CHICAGO
State	:	IL
Zip	:	60614-6037
Country	:	US
Telephone Number	:	847-791-3450
Fax Number	:

Provider Business Practice Location Address
First Line	:	1636 N WELLS ST
Second Line	:	#1807
City	:	CHICAGO
State	:	IL
Zip	:	60614-6037
Country	:	US
Telephone Number	:	847-791-3450
Fax Number	:

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

Provider Enumeration Date	:	02/19/2012
Last Update Date	:	09/17/2012

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