Healthcare Provider Details

I. General information

NPI: 1669204145
Provider Name (Legal Business Name): MIRA FRADKIN MSW, LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2024
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 W HENDERSON ST APT 2N
CHICAGO IL
60657-1491
US

IV. Provider business mailing address

1206 W HENDERSON ST APT 2N
CHICAGO IL
60657-1491
US

V. Phone/Fax

Practice location:
  • Phone: 469-865-7816
  • Fax:
Mailing address:
  • Phone: 469-865-7816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.113813
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: