Healthcare Provider Details

I. General information

NPI: 1710657416
Provider Name (Legal Business Name): LAURA SPOONER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2021
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 W HARRISON ST
CHICAGO IL
60612-3741
US

IV. Provider business mailing address

2622 W CRYSTAL ST UNIT 1
CHICAGO IL
60622-2812
US

V. Phone/Fax

Practice location:
  • Phone: 312-572-4500
  • Fax:
Mailing address:
  • Phone: 815-900-8650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.023532
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: