Healthcare Provider Details

I. General information

NPI: 1730643438
Provider Name (Legal Business Name): ASHLEY BENNETT MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2019
Last Update Date: 01/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865 N CLYBOURN AVE
CHICAGO IL
60618-8269
US

IV. Provider business mailing address

2865 N CLYBOURN AVE
CHICAGO IL
60618-8269
US

V. Phone/Fax

Practice location:
  • Phone: 773-270-0469
  • Fax:
Mailing address:
  • Phone: 773-270-0469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149018003
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: