Provider Demographics
NPI:1003857079
Name:TICKNOR, MARY E (LCSW, LICSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:TICKNOR
Suffix:
Gender:F
Credentials:LCSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 N LA SALLE DR APT 22
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-5845
Mailing Address - Country:US
Mailing Address - Phone:413-374-6135
Mailing Address - Fax:888-335-8179
Practice Address - Street 1:1720 N LA SALLE DR APT 22
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-5845
Practice Address - Country:US
Practice Address - Phone:413-374-6135
Practice Address - Fax:888-335-8179
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490231941041C0700X
MA1131771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP23846Medicare ID - Type Unspecified