Provider Demographics
NPI:1598887580
Name:DETAEGE, PAUL J (LCSW)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:J
Last Name:DETAEGE
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 1:5215 N RAVENSWOOD AVE STE 314
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1670
Mailing Address - Country:US
Mailing Address - Phone:773-988-4965
Mailing Address - Fax:
Practice Address - Street 1:5215 N RAVENSWOOD AVE STE 314
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1670
Practice Address - Country:US
Practice Address - Phone:773-988-4965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0081801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical