Healthcare Provider Details

I. General information

NPI: 1184256232
Provider Name (Legal Business Name): BETHANY BACON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2020
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N MICHIGAN AVE STE 424
CHICAGO IL
60602-3844
US

IV. Provider business mailing address

30 N MICHIGAN AVE STE 424
CHICAGO IL
60602-3844
US

V. Phone/Fax

Practice location:
  • Phone: 312-279-9981
  • Fax:
Mailing address:
  • Phone: 872-274-4344
  • Fax: 866-671-9991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149017452
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: