Healthcare Provider Details

I. General information

NPI: 1801200076
Provider Name (Legal Business Name): BENJAMIN FOGEL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2014
Last Update Date: 02/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 W JACKSON BLVD STE 841
CHICAGO IL
60604-3828
US

IV. Provider business mailing address

2443 N SAWYER AVE APT 1S
CHICAGO IL
60647-2517
US

V. Phone/Fax

Practice location:
  • Phone: 312-478-3999
  • Fax:
Mailing address:
  • Phone: 312-478-3999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.015487
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: