Provider Demographics
NPI:1669953683
Name:D'AGOSTINO, MIA TERESA (LCSW)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:TERESA
Last Name:D'AGOSTINO
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 1:1526 W BELLE PLAINE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1857
Mailing Address - Country:US
Mailing Address - Phone:773-266-8984
Mailing Address - Fax:
Practice Address - Street 1:2500 W BRADLEY PL STE 210
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-4716
Practice Address - Country:US
Practice Address - Phone:475-215-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0175351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical