Healthcare Provider Details

I. General information

NPI: 1134030877
Provider Name (Legal Business Name): MARIAH RHEA FORK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 BOND AVE
EAST SAINT LOUIS IL
62207-2326
US

IV. Provider business mailing address

5900 BOND AVE
EAST SAINT LOUIS IL
62207-2326
US

V. Phone/Fax

Practice location:
  • Phone: 618-332-3060
  • Fax:
Mailing address:
  • Phone: 618-332-3060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149032075
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: