Healthcare Provider Details

I. General information

NPI: 1881423572
Provider Name (Legal Business Name): ADAM DANIEL CONWAY MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 N CLYBOURN AVE STE 520
CHICAGO IL
60614-7923
US

IV. Provider business mailing address

1242 W WINNEMAC AVE APT 2R
CHICAGO IL
60640-2913
US

V. Phone/Fax

Practice location:
  • Phone: 866-729-1012
  • Fax:
Mailing address:
  • Phone: 660-537-1320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.016290
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: