Healthcare Provider Details

I. General information

NPI: 1326339524
Provider Name (Legal Business Name): BETH ILANNA KIBORT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2011
Last Update Date: 04/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4822 N BROADWAY ST 2ND FLOOR
CHICAGO IL
60640-3604
US

IV. Provider business mailing address

2614 FARNSWORTH LN
NORTHBROOK IL
60062-5921
US

V. Phone/Fax

Practice location:
  • Phone: 773-433-1200
  • Fax:
Mailing address:
  • Phone: 312-515-0376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.012596
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: