Provider Demographics
NPI:1922252931
Name:MICHAEL VERNON, LCSW LLC
Entity Type:Organization
Organization Name:MICHAEL VERNON, LCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VERNON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:773-802-6748
Mailing Address - Street 1:1300 W BELMONT AVE
Mailing Address - Street 2:SUITE 20B
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3200
Mailing Address - Country:US
Mailing Address - Phone:773-802-6748
Mailing Address - Fax:773-880-1355
Practice Address - Street 1:1300 W BELMONT AVE
Practice Address - Street 2:SUITE 20B
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3200
Practice Address - Country:US
Practice Address - Phone:773-802-6748
Practice Address - Fax:773-880-1355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490095841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
201666Medicare PIN