Provider Demographics
NPI:1194040329
Name:WITHERS, MARY ELLEN (LCSW, LISW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:WITHERS
Suffix:
Gender:F
Credentials:LCSW, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 N OAK PARK AVE
Mailing Address - Street 2:SUITE#408-1
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1344
Mailing Address - Country:US
Mailing Address - Phone:708-209-8560
Mailing Address - Fax:
Practice Address - Street 1:137 N OAK PARK AVE
Practice Address - Street 2:SUITE#408-1
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1344
Practice Address - Country:US
Practice Address - Phone:708-209-8560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-31
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0071771041C0700X
IL149.0059981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical