Provider Demographics
NPI:1003890450
Name:WALLS, CYNTHIA A (LCSW, PC)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:A
Last Name:WALLS
Suffix:
Gender:F
Credentials:LCSW, PC
Other - Prefix:MRS
Other - First Name:CYNTHIA
Other - Middle Name:ANN
Other - Last Name:CLANCY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3828 N CLAREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-3818
Mailing Address - Country:US
Mailing Address - Phone:773-588-6299
Mailing Address - Fax:
Practice Address - Street 1:53 W JACKSON BLVD STE 626
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-3444
Practice Address - Country:US
Practice Address - Phone:773-469-6299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0030281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S10899Medicare UPIN
ILK18169Medicare ID - Type Unspecified