Healthcare Provider Details

I. General information

NPI: 1164916383
Provider Name (Legal Business Name): SEAN HARRISON SALTZBERG LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E SUPERIOR ST STE 306
CHICAGO IL
60611-2595
US

IV. Provider business mailing address

1340 N DEAN ST
CHICAGO IL
60622-9187
US

V. Phone/Fax

Practice location:
  • Phone: 312-754-9404
  • Fax:
Mailing address:
  • Phone: 224-392-8642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.019583
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: