Provider Demographics
NPI:1215553557
Name:HENDRICKS, COKETHA SAMYRA JEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:COKETHA
Middle Name:SAMYRA JEAN
Last Name:HENDRICKS
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 1:2237 BURR OAK AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-1317
Mailing Address - Country:US
Mailing Address - Phone:312-413-3282
Mailing Address - Fax:
Practice Address - Street 1:641 W 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-2032
Practice Address - Country:US
Practice Address - Phone:312-413-3282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490192931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical