Provider Demographics
NPI:1689092348
Name:MINSHALL, MARCY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARCY
Middle Name:
Last Name:MINSHALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9649 W 55TH ST
Mailing Address - Street 2:
Mailing Address - City:COUNTRYSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-3632
Mailing Address - Country:US
Mailing Address - Phone:708-482-8646
Mailing Address - Fax:708-352-3763
Practice Address - Street 1:9649 W 55TH ST
Practice Address - Street 2:
Practice Address - City:COUNTRYSIDE
Practice Address - State:IL
Practice Address - Zip Code:60525-3632
Practice Address - Country:US
Practice Address - Phone:708-482-8646
Practice Address - Fax:708-352-3763
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490085501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid