Provider Demographics
NPI:1841236643
Name:DOTY, MARY ALEXANDRA PW (MSSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY ALEXANDRA
Middle Name:PW
Last Name:DOTY
Suffix:
Gender:F
Credentials:MSSW, LCSW
Other - Prefix:MS
Other - First Name:ALEX
Other - Middle Name:
Other - Last Name:DOTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSSW, LCSW
Mailing Address - Street 1:732 HINMAN AVE
Mailing Address - Street 2:APT. 3E
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-4414
Mailing Address - Country:US
Mailing Address - Phone:847-328-5874
Mailing Address - Fax:
Practice Address - Street 1:3003 W TOUHY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-2833
Practice Address - Country:US
Practice Address - Phone:773-508-1000
Practice Address - Fax:773-262-7084
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205555Medicare PIN