Provider Demographics
NPI:1598463184
Name:WETTSTEIN, JUSTIN (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:WETTSTEIN
Suffix:
Gender:M
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 1:2000 N RACINE AVE STE 3300
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-7008
Mailing Address - Country:US
Mailing Address - Phone:773-413-9523
Mailing Address - Fax:
Practice Address - Street 1:4621 N RAVENSWOOD AVE FL 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4509
Practice Address - Country:US
Practice Address - Phone:773-413-9523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL15863042Medicaid