Provider Demographics
NPI:1326045170
Name:ROMAINE, JUDITH ANN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:ANN
Last Name:ROMAINE
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 1:15507 MINERVA AVE
Mailing Address - Street 2:
Mailing Address - City:DOLTON
Mailing Address - State:IL
Mailing Address - Zip Code:60419-2722
Mailing Address - Country:US
Mailing Address - Phone:708-206-0495
Mailing Address - Fax:708-841-0185
Practice Address - Street 1:19150 KEDZIE
Practice Address - Street 2:STE 205
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422
Practice Address - Country:US
Practice Address - Phone:708-206-0495
Practice Address - Fax:708-411-0185
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211166Medicare ID - Type UnspecifiedPROVIDER NUMBER