Provider Demographics
NPI:1629790761
Name:PENTZ, CARLIANN
Entity Type:Individual
Prefix:
First Name:CARLIANN
Middle Name:
Last Name:PENTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 MICHIGAN AVE APT H3
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3037
Mailing Address - Country:US
Mailing Address - Phone:815-529-3665
Mailing Address - Fax:
Practice Address - Street 1:540 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3037
Practice Address - Country:US
Practice Address - Phone:815-529-3665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-15
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150109067104100000X
IL1490250721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker