Healthcare Provider Details

I. General information

NPI: 1295194710
Provider Name (Legal Business Name): MARY ANN CLEARY LCSW, CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2016
Last Update Date: 05/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5517 N KENMORE AVE
CHICAGO IL
60640
US

IV. Provider business mailing address

1280 W VICTORIA ST
CHICAGO IL
60660-3959
US

V. Phone/Fax

Practice location:
  • Phone: 773-275-7962
  • Fax: 773-561-5497
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number32954
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150101658
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149020354
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: