Healthcare Provider Details

I. General information

NPI: 1093396764
Provider Name (Legal Business Name): CORY GRAPENTHIEN BEDTKE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 04/15/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6538 N NORTHWEST HWY APT 1I
CHICAGO IL
60631-4002
US

IV. Provider business mailing address

6538 N NORTHWEST HWY APT 1I
CHICAGO IL
60631-4002
US

V. Phone/Fax

Practice location:
  • Phone: 312-330-1250
  • Fax:
Mailing address:
  • Phone: 312-330-1250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149021114
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: