Provider Demographics
NPI:1114137163
Name:OLDER, MOLLY (LCSW)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:OLDER
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 1:943 N WOLCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-4941
Mailing Address - Country:US
Mailing Address - Phone:773-394-9638
Mailing Address - Fax:
Practice Address - Street 1:1969 W OGDEN AVE
Practice Address - Street 2:ROOM 1698
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3765
Practice Address - Country:US
Practice Address - Phone:312-864-2404
Practice Address - Fax:312-864-9238
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
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