Provider Demographics
NPI:1376814038
Name:BROOM, ANGELA NICOLE (LCSW)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:NICOLE
Last Name:BROOM
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 1:552 52ND AVE
Mailing Address - Street 2:
Mailing Address - City:BELLWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60104-1761
Mailing Address - Country:US
Mailing Address - Phone:708-925-2966
Mailing Address - Fax:708-486-0145
Practice Address - Street 1:552 52ND AVE
Practice Address - Street 2:
Practice Address - City:BELLWOOD
Practice Address - State:IL
Practice Address - Zip Code:60104-1761
Practice Address - Country:US
Practice Address - Phone:708-925-2966
Practice Address - Fax:708-486-0145
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490112181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical