Provider Demographics
NPI:1275807158
Name:EDEH, AUGUSTUS C (LCSW)
Entity Type:Individual
Prefix:
First Name:AUGUSTUS
Middle Name:C
Last Name:EDEH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5658 S KOLIN AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-4839
Mailing Address - Country:US
Mailing Address - Phone:773-412-7420
Mailing Address - Fax:
Practice Address - Street 1:5658 S KOLIN AVE UNIT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4839
Practice Address - Country:US
Practice Address - Phone:773-412-7420
Practice Address - Fax:773-306-2675
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-24
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0150781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical