1619008992 NPI number — DR. LAURA MICK DENATALE PH.D., L.C.S.W.

Table of content: DR. LAURA MICK DENATALE PH.D., L.C.S.W. (NPI 1619008992)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619008992 NPI number — DR. LAURA MICK DENATALE PH.D., L.C.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DENATALE
Provider First Name:
LAURA
Provider Middle Name:
MICK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D., L.C.S.W.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OROGUN
Provider Other First Name:
LAURA
Provider Other Middle Name:
MICK
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
L.C.S.W.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619008992
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6700 N MAPLEWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60645-4620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-602-2876
Provider Business Mailing Address Fax Number:
847-602-2876

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
636 CHURCH ST STE 406
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVANSTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60201-4580
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-602-2876
Provider Business Practice Location Address Fax Number:
847-602-2876
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  0149008148 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01622876 . This is a "BCBSIL PIN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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