Healthcare Provider Details

I. General information

NPI: 1376458950
Provider Name (Legal Business Name): TASHA MARIE WEATHERSBY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461 E 111TH ST
CHICAGO IL
60628-4558
US

IV. Provider business mailing address

461 E 111TH ST
CHICAGO IL
60628-4558
US

V. Phone/Fax

Practice location:
  • Phone: 773-419-4960
  • Fax: 773-629-8087
Mailing address:
  • Phone: 773-419-4960
  • Fax: 773-629-8087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number150.112787
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: