Provider Demographics
NPI:1073152898
Name:ROSENBERG, AVIVA (LCSW)
Entity Type:Individual
Prefix:
First Name:AVIVA
Middle Name:
Last Name:ROSENBERG
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 1:655 W IRVING PARK RD APT 5514
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-6311
Mailing Address - Country:US
Mailing Address - Phone:973-715-6450
Mailing Address - Fax:
Practice Address - Street 1:2754 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-6870
Practice Address - Country:US
Practice Address - Phone:312-762-2749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.021661101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool