Provider Demographics
NPI:1821705229
Name:HARTLINE, ROGER (LCSW)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:HARTLINE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:ROGER
Other - Middle Name:
Other - Last Name:SCHMIED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:272 S PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-2038
Mailing Address - Country:US
Mailing Address - Phone:815-944-2501
Mailing Address - Fax:
Practice Address - Street 1:272 S PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-2038
Practice Address - Country:US
Practice Address - Phone:815-944-2501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-04
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0269711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149.026971OtherSTATE OF ILLINOIS
IL149.026971OtherLICENSED CLINICAL SOCIAL WORKER