Provider Demographics
NPI:1184602427
Name:FORD, VANESSA ERICA (LCSW, CADC)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:ERICA
Last Name:FORD
Suffix:
Gender:F
Credentials:LCSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 W ROOSEVELT RD
Mailing Address - Street 2:UNIT # 409
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1671
Mailing Address - Country:US
Mailing Address - Phone:773-552-8070
Mailing Address - Fax:
Practice Address - Street 1:4003 N BROADWAY ST
Practice Address - Street 2:SUITE 6
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2110
Practice Address - Country:US
Practice Address - Phone:773-552-8070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL22776101YA0400X
IL1490099941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)