Healthcare Provider Details

I. General information

NPI: 1154614634
Provider Name (Legal Business Name): JULIET ANN RUSSOM WALDEN BS, AM, LSCW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2011
Last Update Date: 06/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13136 WESTERN AVE
BLUE ISLAND IL
60406-2423
US

IV. Provider business mailing address

1945 W 22ND PL
CHICAGO IL
60608-4205
US

V. Phone/Fax

Practice location:
  • Phone: 708-974-5800
  • Fax:
Mailing address:
  • Phone: 773-247-6689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.014305
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: