Healthcare Provider Details

I. General information

NPI: 1548673866
Provider Name (Legal Business Name): EMILY MCKERNAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2014
Last Update Date: 06/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5710 N BROADWAY AVE
CHICAGO IL
60660
US

IV. Provider business mailing address

5710 N BROADWAY AVE
CHICAGO IL
60660
US

V. Phone/Fax

Practice location:
  • Phone: 773-765-0515
  • Fax: 773-765-0401
Mailing address:
  • Phone: 773-765-0515
  • Fax: 773-765-0401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.016695
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: