Provider Demographics
NPI:1346691946
Name:FAIRGRIEVE, AMANDA CREDEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:CREDEN
Last Name:FAIRGRIEVE
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 1:1611 W HARRISON ST STE 106B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4861
Mailing Address - Country:US
Mailing Address - Phone:312-563-0830
Mailing Address - Fax:
Practice Address - Street 1:1611 W HARRISON ST STE 106B
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4861
Practice Address - Country:US
Practice Address - Phone:312-563-0830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-24
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0185891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical