Healthcare Provider Details

I. General information

NPI: 1891273900
Provider Name (Legal Business Name): FERNANDO GONZALEZ III LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2018
Last Update Date: 04/01/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 E OHIO ST # 271
CHICAGO IL
60611-4092
US

IV. Provider business mailing address

207 E OHIO ST # 271
CHICAGO IL
60611-4092
US

V. Phone/Fax

Practice location:
  • Phone: 708-351-8212
  • Fax:
Mailing address:
  • Phone: 708-351-8212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150102999
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.021105
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: