Healthcare Provider Details

I. General information

NPI: 1881510295
Provider Name (Legal Business Name): PHUONG-THAO NGUYEN LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4707 N BROADWAY ST STE 304
CHICAGO IL
60640-7900
US

IV. Provider business mailing address

4707 N BROADWAY ST STE 304
CHICAGO IL
60640-7900
US

V. Phone/Fax

Practice location:
  • Phone: 810-701-8029
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150113853
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: