Healthcare Provider Details

I. General information

NPI: 1689169526
Provider Name (Legal Business Name): CECELIA BOZEMAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2018
Last Update Date: 06/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 W BOUGHTON RD STE 104
BOLINGBROOK IL
60440-1400
US

IV. Provider business mailing address

1531 WATKINS LN UNIT 101
NAPERVILLE IL
60540-9264
US

V. Phone/Fax

Practice location:
  • Phone: 331-318-8181
  • Fax: 630-863-7293
Mailing address:
  • Phone: 312-685-0718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.018998
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: