Provider Demographics
NPI:1003030370
Name:ROSEN, GREG (LCSW)
Entity Type:Individual
Prefix:MR
First Name:GREG
Middle Name:
Last Name:ROSEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 E 53RD ST
Mailing Address - Street 2:#630
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4557
Mailing Address - Country:US
Mailing Address - Phone:773-752-8808
Mailing Address - Fax:
Practice Address - Street 1:1525 E 53RD ST
Practice Address - Street 2:#630
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4557
Practice Address - Country:US
Practice Address - Phone:773-752-8808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0068681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
26-3608931OtherEIN
796830Medicare ID - Type Unspecified