Provider Demographics
NPI:1053474460
Name:TRADER, MICHAEL JOHN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOHN
Last Name:TRADER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 S PHELPS AVE
Mailing Address - Street 2:SUITE 818
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2453
Mailing Address - Country:US
Mailing Address - Phone:815-229-6316
Mailing Address - Fax:815-229-6316
Practice Address - Street 1:129 PHELPS AVE
Practice Address - Street 2:SUITE 818
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2453
Practice Address - Country:US
Practice Address - Phone:815-229-6316
Practice Address - Fax:815-229-6316
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
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
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0010171232OtherBCBS OF ILLINOIS
IL939300Medicare ID - Type Unspecified