Provider Demographics
NPI:1558498311
Name:ROSE, LAUREEN ANN (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:LAUREEN
Middle Name:ANN
Last Name:ROSE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4719 N SACRAMENTO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-4305
Mailing Address - Country:US
Mailing Address - Phone:773-529-7070
Mailing Address - Fax:
Practice Address - Street 1:2604 DEMPSTER ST
Practice Address - Street 2:SUITE 306
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-8412
Practice Address - Country:US
Practice Address - Phone:847-827-8297
Practice Address - Fax:847-827-8474
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1608239OtherBLUE CROSS BLUE SHIELD
IL942810Medicare ID - Type UnspecifiedPROVIDER NUMBER