Provider Demographics
NPI:1659352573
Name:NATHANSON, IRENE G (LCSW)
Entity Type:Individual
Prefix:MS
First Name:IRENE
Middle Name:G
Last Name:NATHANSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:RENA
Other - Middle Name:
Other - Last Name:NATHANSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:20372 N 110TH LN
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85373-2304
Mailing Address - Country:US
Mailing Address - Phone:623-225-7365
Mailing Address - Fax:
Practice Address - Street 1:20372 N 110TH LN
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85373-2304
Practice Address - Country:US
Practice Address - Phone:623-225-7365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2011-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004542A1041C0700X
IL149-0066551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN232340Medicare ID - Type Unspecified