Healthcare Provider Details

I. General information

NPI: 1881256154
Provider Name (Legal Business Name): AUDRA STOLZ MASTERTON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 W FOSTER AVE STE 113
CHICAGO IL
60625-3547
US

IV. Provider business mailing address

2740 W FOSTER AVE STE 113
CHICAGO IL
60625-3547
US

V. Phone/Fax

Practice location:
  • Phone: 773-293-5300
  • Fax: 773-293-5346
Mailing address:
  • Phone: 773-293-5300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number149018336
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.018336
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: