Healthcare Provider Details

I. General information

NPI: 1962739110
Provider Name (Legal Business Name): ANNELIESE MOY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2009
Last Update Date: 06/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3916 N NEVA AVE
CHICAGO IL
60634-2228
US

IV. Provider business mailing address

3916 N NEVA AVE
CHICAGO IL
60634-2228
US

V. Phone/Fax

Practice location:
  • Phone: 773-615-6538
  • Fax:
Mailing address:
  • Phone: 773-615-6538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149012913
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: