Healthcare Provider Details

I. General information

NPI: 1417601550
Provider Name (Legal Business Name): CAROLINE WYSGALLA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2022
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 N CLARK ST STE 305
CHICAGO IL
60610-7862
US

IV. Provider business mailing address

1165 N CLARK ST STE 305
CHICAGO IL
60610-7862
US

V. Phone/Fax

Practice location:
  • Phone: 312-880-9913
  • Fax: 844-787-9891
Mailing address:
  • Phone: 312-880-9913
  • Fax: 844-787-9891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.028147
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: