Provider Demographics
NPI:1609386168
Name:PEDERSEN, PAUL MCARTHUR (LSW)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:MCARTHUR
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5220 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:COUNTRYSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-3133
Mailing Address - Country:US
Mailing Address - Phone:708-995-3598
Mailing Address - Fax:
Practice Address - Street 1:22 W CALENDAR AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2373
Practice Address - Country:US
Practice Address - Phone:708-745-5277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-10
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.102135104100000X
IL1490215301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker