Provider Demographics
NPI:1598864035
Name:WIECZOREK, LAWRENCE MICHAEL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:MICHAEL
Last Name:WIECZOREK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 BURLINGTON AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WESTERN SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60558-1575
Mailing Address - Country:US
Mailing Address - Phone:630-969-2810
Mailing Address - Fax:630-969-2810
Practice Address - Street 1:901 BURLINGTON AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:WESTERN SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60558-1575
Practice Address - Country:US
Practice Address - Phone:630-969-2810
Practice Address - Fax:630-969-2810
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
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
IL04971454OtherBLUE CROSS BLUE SHIELD
IL02273040OtherBLUE CROSS BLUE SHIELD
IL04971454OtherBLUE CROSS BLUE SHIELD