Provider Demographics
NPI:1093029407
Name:MARGUERITE J HENDERSON LCSW PC
Entity Type:Organization
Organization Name:MARGUERITE J HENDERSON LCSW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:MARGUERITE
Authorized Official - Middle Name:J
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:773-645-3457
Mailing Address - Street 1:1431 N WESTERN AVE
Mailing Address - Street 2:SUITE 504
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1797
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:773-645-3453
Practice Address - Street 1:1431 N WESTERN AVE
Practice Address - Street 2:SUITE 504
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1797
Practice Address - Country:US
Practice Address - Phone:773-645-3457
Practice Address - Fax:773-645-3453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-28
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490067831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1861429847OtherPERSONAL NPI
IL210507OtherMEDICARE PTAN
IL149006783OtherSTATE LICENSE