MEDICARE: TAYLOR J UNDERWOOD

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	104100000X	Social Worker
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1952906109
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TAYLOR J UNDERWOOD

Provider Business Mailing Address
First Line	:	2255 S HIGHLAND AVE APT 406
Second Line	:
City	:	LOMBARD
State	:	IL
Zip	:	60148-5329
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3205 N WILKE RD # 102E
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-0001
Country	:	US
Telephone Number	:	815-993-8311
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TAYLOR UNDERWOOD
Credential	:	LCSW
Telephone Number	:	815-993-8831

Provider Enumeration Date	:	12/03/2020
Last Update Date	:	06/22/2021

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