Provider Demographics
NPI:1114939055
Name:WHITLOCK, AMANDA ROSE (LCSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:WHITLOCK
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 1:9711 SKOKIE BLVD
Mailing Address - Street 2:SUITE H
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-1384
Mailing Address - Country:US
Mailing Address - Phone:773-719-2140
Mailing Address - Fax:
Practice Address - Street 1:9711 SKOKIE BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1384
Practice Address - Country:US
Practice Address - Phone:773-719-2140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2014-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0094211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical