Healthcare Provider Details

I. General information

NPI: 1174228233
Provider Name (Legal Business Name): MICKAYLA BEDENIAN LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2023
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

579 W NORTH AVE STE 206
ELMHURST IL
60126-2144
US

IV. Provider business mailing address

579 W NORTH AVE STE 206
ELMHURST IL
60126-2144
US

V. Phone/Fax

Practice location:
  • Phone: 630-384-9499
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150105402
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: