Provider Demographics
NPI:1184346587
Name:BLUE, MARIYA (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:MARIYA
Middle Name:
Last Name:BLUE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9074 W TERRACE DR APT 4B
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-5852
Mailing Address - Country:US
Mailing Address - Phone:224-250-1228
Mailing Address - Fax:
Practice Address - Street 1:444 S RAND RD STE 300
Practice Address - Street 2:
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-2307
Practice Address - Country:US
Practice Address - Phone:847-492-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0203301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty