Provider Demographics
NPI:1518556778
Name:MAYTORENA-UNGER, FERNANDA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:FERNANDA
Middle Name:
Last Name:MAYTORENA-UNGER
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 1:3547 RIDGELAND AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3848
Mailing Address - Country:US
Mailing Address - Phone:708-567-7342
Mailing Address - Fax:708-780-7423
Practice Address - Street 1:6925 CERMAK RD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2248
Practice Address - Country:US
Practice Address - Phone:708-780-7400
Practice Address - Fax:708-780-7423
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2021-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490225111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149022511OtherLICENSE