MEDICARE: ANTOINETTE M DEZZUTTI LCSW PC

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

General Provider Information

NPI Number	:	1942695226
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANTOINETTE M DEZZUTTI LCSW PC

Provider Business Mailing Address
First Line	:	6237 N LAKEWOOD AVE
Second Line	:	APT 3A
City	:	CHICAGO
State	:	IL
Zip	:	60660-1954
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	954 W WASHINGTON BLVD
Second Line	:	STE 402 BOX 14
City	:	CHICAGO
State	:	IL
Zip	:	60607-2224
Country	:	US
Telephone Number	:	773-891-6729
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ANTOINETTE M DEZZUTTI
Credential	:	LCSW
Telephone Number	:	773-891-6729

Provider Enumeration Date	:	04/02/2015
Last Update Date	:	04/02/2015

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