Provider Demographics
NPI:1881256154
Name:MASTERTON, AUDRA STOLZ (LCSW)
Entity type:Individual
Prefix:MS
First Name:AUDRA
Middle Name:STOLZ
Last Name:MASTERTON
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 1:2740 W FOSTER AVE STE 113
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3547
Mailing Address - Country:US
Mailing Address - Phone:773-293-5300
Mailing Address - Fax:
Practice Address - Street 1:2740 W FOSTER AVE STE 113
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3547
Practice Address - Country:US
Practice Address - Phone:773-293-5300
Practice Address - Fax:773-293-5346
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149018336104100000X
IL149.0183361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker