Healthcare Provider Details

I. General information

NPI: 1689189078
Provider Name (Legal Business Name): JOHN BOZEDAY LCSW LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2017
Last Update Date: 12/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 CHURCH ST STE 258
EVANSTON IL
60201-3840
US

IV. Provider business mailing address

235 RIDGE RD APT 4C
WILMETTE IL
60091-3252
US

V. Phone/Fax

Practice location:
  • Phone: 847-251-0346
  • Fax:
Mailing address:
  • Phone: 847-251-0346
  • Fax: 847-251-0346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149003005
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number149003005
License Number StateIL

VIII. Authorized Official

Name: MR. JOHN BOZEDAY
Title or Position: PRESIDENT
Credential: LCSW
Phone: 847-251-0346