Provider Demographics
NPI:1598807711
Name:KOVACIN, JULIE A (LCSW)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:A
Last Name:KOVACIN
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 1:120 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-3132
Mailing Address - Country:US
Mailing Address - Phone:847-508-4607
Mailing Address - Fax:
Practice Address - Street 1:4840 W BYRON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-2712
Practice Address - Country:US
Practice Address - Phone:773-282-7800
Practice Address - Fax:773-282-2163
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
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
IL347230Medicare ID - Type Unspecified