Healthcare Provider Details

I. General information

NPI: 1689343147
Provider Name (Legal Business Name): HEATHER FLETT MA, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 N BROADWAY ST
CHICAGO IL
60613-2110
US

IV. Provider business mailing address

1937 W SCHILLER ST
CHICAGO IL
60622-1913
US

V. Phone/Fax

Practice location:
  • Phone: 773-510-1782
  • Fax:
Mailing address:
  • Phone: 773-510-1782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149009134
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: