Provider Demographics
NPI:1164916383
Name:SALTZBERG, SEAN HARRISON (LCSW)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:HARRISON
Last Name:SALTZBERG
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 1:1340 N DEAN ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-9187
Mailing Address - Country:US
Mailing Address - Phone:224-392-8642
Mailing Address - Fax:
Practice Address - Street 1:1 E SUPERIOR ST STE 306
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2595
Practice Address - Country:US
Practice Address - Phone:312-754-9404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0195831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$Medicaid