MEDICARE: INNER WISDOM 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	149013726	IL

General Provider Information

NPI Number	:	1992094312
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNER WISDOM COUNSELING, LLC

Provider Business Mailing Address
First Line	:	5756 N RIDGE AVE
Second Line	:	SUITE #10
City	:	CHICAGO
State	:	IL
Zip	:	60660-5331
Country	:	US
Telephone Number	:	312-730-7377
Fax Number	:

Provider Business Practice Location Address
First Line	:	5756 N RIDGE AVE
Second Line	:	SUITE #10
City	:	CHICAGO
State	:	IL
Zip	:	60660-5331
Country	:	US
Telephone Number	:	312-730-7377
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ELIZABETH WHITE
Credential	:	LCSW
Telephone Number	:	312-730-7377

Provider Enumeration Date	:	04/06/2011
Last Update Date	:	04/06/2011

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