Provider Demographics
NPI:1134990161
Name:SIEGEL-ELLIOTT, MALLORY (LMSW)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:SIEGEL-ELLIOTT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8765 W HIGGINS RD STE 450
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-4172
Mailing Address - Country:US
Mailing Address - Phone:773-693-0300
Mailing Address - Fax:
Practice Address - Street 1:3753 S COTTAGE GROVE AVE STE 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-1662
Practice Address - Country:US
Practice Address - Phone:773-693-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.1124341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical