Provider Demographics
NPI:1225434236
Name:VERGOTH, JOANNA (LCSW)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:VERGOTH
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 1:3150 N LAKE SHORE DR
Mailing Address - Street 2:APT 18F
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-4810
Mailing Address - Country:US
Mailing Address - Phone:917-796-8213
Mailing Address - Fax:
Practice Address - Street 1:4753 N BROADWAY ST
Practice Address - Street 2:SUITE 509
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5266
Practice Address - Country:US
Practice Address - Phone:917-796-8213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0085681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical