Provider Demographics
NPI:1225403652
Name:KEFLE, TESFAMARIAM (LCSW)
Entity Type:Individual
Prefix:
First Name:TESFAMARIAM
Middle Name:
Last Name:KEFLE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:TES
Other - Middle Name:
Other - Last Name:KEFLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6240 N DRAKE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-2204
Mailing Address - Country:US
Mailing Address - Phone:773-577-6178
Mailing Address - Fax:847-390-8214
Practice Address - Street 1:1609 SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3753
Practice Address - Country:US
Practice Address - Phone:773-577-6178
Practice Address - Fax:847-390-8214
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-10
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0098751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149.009875OtherLICENSE NUMBER