Provider Demographics
NPI:1215034756
Name:MANCILLAS, ANDREA G (LSW)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:G
Last Name:MANCILLAS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 N. SANDBURG TERR., APT. 514
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-6323
Mailing Address - Country:US
Mailing Address - Phone:312-569-8387
Mailing Address - Fax:312-569-6130
Practice Address - Street 1:820 S DAMEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3728
Practice Address - Country:US
Practice Address - Phone:312-569-8387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker