Provider Demographics
NPI:1003871542
Name:PREMACK, MERLE A (MSW, LCSW, BCD)
Entity Type:Individual
Prefix:MS
First Name:MERLE
Middle Name:A
Last Name:PREMACK
Suffix:
Gender:F
Credentials:MSW, LCSW, BCD
Other - Prefix:
Other - First Name:MERLE
Other - Middle Name:A
Other - Last Name:ISEBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2031 E GRAND AVE
Mailing Address - Street 2:SUITE # 300
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-9041
Mailing Address - Country:US
Mailing Address - Phone:847-778-3575
Mailing Address - Fax:847-676-9979
Practice Address - Street 1:2031 E GRAND AVE
Practice Address - Street 2:SUITE # 300
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-9041
Practice Address - Country:US
Practice Address - Phone:847-778-3575
Practice Address - Fax:847-676-9979
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical