Healthcare Provider Details

I. General information

NPI: 1184040032
Provider Name (Legal Business Name): ELLEN TANNENBAUM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2014
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 N LA SALLE DR
CHICAGO IL
60654-3503
US

IV. Provider business mailing address

721 N LA SALLE DR
CHICAGO IL
60654-3503
US

V. Phone/Fax

Practice location:
  • Phone: 773-551-3067
  • Fax: 312-236-5384
Mailing address:
  • Phone: 773-551-3067
  • Fax: 312-236-5384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.012695
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: