Provider Demographics
NPI:1124585310
Name:MALONE, AMY B (LCSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:B
Last Name:MALONE
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 1:615 S STONE AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2723
Mailing Address - Country:US
Mailing Address - Phone:708-712-1984
Mailing Address - Fax:
Practice Address - Street 1:6040 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-3392
Practice Address - Country:US
Practice Address - Phone:630-524-4000
Practice Address - Fax:630-524-2311
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0021881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty