Provider Demographics
NPI:1255131199
Name:MANSHUM, CARLY (BSW)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:MANSHUM
Suffix:
Gender:
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 E OGDEN AVE UNIT 337
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2132
Mailing Address - Country:US
Mailing Address - Phone:773-680-2275
Mailing Address - Fax:
Practice Address - Street 1:1340 S DAMEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1169
Practice Address - Country:US
Practice Address - Phone:773-680-2275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-18
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health