Provider Demographics
NPI:1164854790
Name:TEGENKAMP, EMILY (MA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:TEGENKAMP
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3145 W PRATT BLVD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-4125
Mailing Address - Country:US
Mailing Address - Phone:773-467-3741
Mailing Address - Fax:
Practice Address - Street 1:3145 W PRATT BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-4125
Practice Address - Country:US
Practice Address - Phone:773-467-3741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.013429104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker