Provider Demographics
NPI:1780152488
Name:KRAVITZ, MIMI S (MSW;LCSW)
Entity type:Individual
Prefix:MS
First Name:MIMI
Middle Name:S
Last Name:KRAVITZ
Suffix:
Gender:F
Credentials:MSW;LCSW
Other - Prefix:
Other - First Name:MIMI
Other - Middle Name:KRAVITZ
Other - Last Name:DEWOSKIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:464 CENTRAL AVE STE 30
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-3030
Mailing Address - Country:US
Mailing Address - Phone:847-226-5562
Mailing Address - Fax:
Practice Address - Street 1:464 CENTRAL AVE STE 30
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-3030
Practice Address - Country:US
Practice Address - Phone:847-226-5562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490063811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical