Provider Demographics
NPI:1396956538
Name:MACIULIS, PHYLLIS GOLDBERG (LCSW)
Entity type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:GOLDBERG
Last Name:MACIULIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 W 21ST PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-4305
Mailing Address - Country:US
Mailing Address - Phone:312-218-6627
Mailing Address - Fax:312-506-0103
Practice Address - Street 1:1801 W 21ST PL
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-4305
Practice Address - Country:US
Practice Address - Phone:312-218-6627
Practice Address - Fax:312-506-0103
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0085451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL201616Medicare ID - Type UnspecifiedPROVIDER # FOR LCSW BILLI