Provider Demographics
NPI:1184040032
Name:TANNENBAUM, ELLEN (LCSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:TANNENBAUM
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 1:2310 W ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1131
Mailing Address - Country:US
Mailing Address - Phone:312-655-7991
Mailing Address - Fax:312-236-5384
Practice Address - Street 1:2310 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1131
Practice Address - Country:US
Practice Address - Phone:312-655-7991
Practice Address - Fax:312-236-5384
Is Sole Proprietor?:No
Enumeration Date:2014-03-14
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0126951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical