Provider Demographics
NPI:1598747461
Name:PETTY, MARY LOU (MSW LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY LOU
Middle Name:
Last Name:PETTY
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:MARY LOU
Other - Middle Name:
Other - Last Name:TREZISE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:30 N MICHIGAN AVE
Mailing Address - Street 2:STE 1004
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3402
Mailing Address - Country:US
Mailing Address - Phone:312-236-4364
Mailing Address - Fax:
Practice Address - Street 1:30 N MICHIGAN AVE
Practice Address - Street 2:STE 1004
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3402
Practice Address - Country:US
Practice Address - Phone:312-236-4364
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-16
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
0005983663OtherAETNA
190629OtherVALUE OPTIONS
5906676720OtherUNITED BEHAVIORAL HEALTH
IL01673624OtherBCBS
190629OtherVALUE OPTIONS
956340Medicare ID - Type Unspecified
IL341410Medicare ID - Type UnspecifiedGROUP
5906676720OtherUNITED BEHAVIORAL HEALTH