Provider Demographics
NPI:1245836345
Name:GOLDFARB, MIRIAM BETH (LSW)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:BETH
Last Name:GOLDFARB
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2024 W HADDON AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3600
Mailing Address - Country:US
Mailing Address - Phone:612-240-2369
Mailing Address - Fax:
Practice Address - Street 1:3711 N RAVENSWOOD AVE STE 146
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-5944
Practice Address - Country:US
Practice Address - Phone:612-240-2369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-05
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150104778104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker