Provider Demographics
NPI:1114183266
Name:TICE, LAWRENCE CLINTON (LCSW)
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:CLINTON
Last Name:TICE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 S EAST END AVE APT 7C
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-3177
Mailing Address - Country:US
Mailing Address - Phone:773-363-6757
Mailing Address - Fax:
Practice Address - Street 1:5000 S EAST AVE APT 7C
Practice Address - Street 2:APT 7C
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-3177
Practice Address - Country:US
Practice Address - Phone:773-363-6757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0017711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical