Healthcare Provider Details

I. General information

NPI: 1073171120
Provider Name (Legal Business Name): ALIA MIR LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 S DAMEN AVE # C
CHICAGO IL
60608-1169
US

IV. Provider business mailing address

1340 S DAMEN AVE # C
CHICAGO IL
60608-1169
US

V. Phone/Fax

Practice location:
  • Phone: 773-207-0593
  • Fax:
Mailing address:
  • Phone: 773-207-0593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149017788
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: