Provider Demographics
NPI:1700234630
Name:BAILON, MAYRA A (LCSW)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:A
Last Name:BAILON
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 1:446 E ONTARIO ST STE 6-100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4418
Mailing Address - Country:US
Mailing Address - Phone:312-926-8200
Mailing Address - Fax:312-926-7960
Practice Address - Street 1:446 E ONTARIO ST STE 6-100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4418
Practice Address - Country:US
Practice Address - Phone:312-926-8200
Practice Address - Fax:312-926-7960
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490173761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGMedicaid
ILPENDINGMedicare Oscar/Certification