Provider Demographics
NPI:1437686748
Name:MYERS, MARY AMANDA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:AMANDA
Last Name:MYERS
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 1:1921 N MOZART ST # 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-3932
Mailing Address - Country:US
Mailing Address - Phone:407-929-1016
Mailing Address - Fax:
Practice Address - Street 1:1747 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1264
Practice Address - Country:US
Practice Address - Phone:312-996-7723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-17
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150102213104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker