Healthcare Provider Details

I. General information

NPI: 1184265597
Provider Name (Legal Business Name): BONITA RICHARDSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W DEVON AVE
CHICAGO IL
60660-1302
US

IV. Provider business mailing address

1300 W DEVON AVE
CHICAGO IL
60660-1302
US

V. Phone/Fax

Practice location:
  • Phone: 773-751-7850
  • Fax: 773-751-7855
Mailing address:
  • Phone: 773-751-7850
  • Fax: 773-751-7855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.020950
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: