Provider Demographics
NPI:1114090040
Name:OMAHEN, MARILYN B (LCSW, RDDP)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:B
Last Name:OMAHEN
Suffix:
Gender:F
Credentials:LCSW, RDDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1923 NEW WILLOW RD APT 6
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-2944
Mailing Address - Country:US
Mailing Address - Phone:847-446-0448
Mailing Address - Fax:
Practice Address - Street 1:456 W FRONTAGE RD STE 2
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-3038
Practice Address - Country:US
Practice Address - Phone:847-446-0448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL25616101YA0400X
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK07584Medicare ID - Type Unspecified