Provider Demographics
NPI:1578118964
Name:BERBAUM AUSSEM, AMANDA LYNN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LYNN
Last Name:BERBAUM AUSSEM
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 1:5017 W BERTEAU AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-1738
Mailing Address - Country:US
Mailing Address - Phone:847-507-9823
Mailing Address - Fax:
Practice Address - Street 1:84 S STONINGTON DR
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60074-6801
Practice Address - Country:US
Practice Address - Phone:847-507-9823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-03
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490101681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical