Provider Demographics
NPI:1669053732
Name:HARTH, DANIELLE NICOLE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:NICOLE
Last Name:HARTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5425 W 108TH PL
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-5032
Mailing Address - Country:US
Mailing Address - Phone:630-873-9681
Mailing Address - Fax:
Practice Address - Street 1:2150 W LAWRENCE AVE STE A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-1582
Practice Address - Country:US
Practice Address - Phone:773-887-6447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.012220101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL178.012220Medicaid