Provider Demographics
NPI:1558141127
Name:MOOG, COLETTE NAWAL (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:COLETTE
Middle Name:NAWAL
Last Name:MOOG
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W BRADLEY PL STE 109
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-4716
Mailing Address - Country:US
Mailing Address - Phone:773-332-9439
Mailing Address - Fax:773-754-8730
Practice Address - Street 1:2500 W BRADLEY PL STE 109
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-4716
Practice Address - Country:US
Practice Address - Phone:773-332-9439
Practice Address - Fax:773-754-8730
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150111660104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker