Healthcare Provider Details

I. General information

NPI: 1225403652
Provider Name (Legal Business Name): TESFAMARIAM KEFLE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: TES KEFLE

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 SHERMAN AVE
EVANSTON IL
60201-3753
US

IV. Provider business mailing address

6240 N DRAKE AVE
CHICAGO IL
60659-2204
US

V. Phone/Fax

Practice location:
  • Phone: 773-577-6178
  • Fax: 847-390-8214
Mailing address:
  • Phone: 773-577-6178
  • Fax: 847-390-8214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.009875
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: