Healthcare Provider Details

I. General information

NPI: 1790058543
Provider Name (Legal Business Name): CARRIE JEAN STELNICKI L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2012
Last Update Date: 02/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 OAK AVE
EVANSTON IL
60202-1221
US

IV. Provider business mailing address

1234 OAK AVE
EVANSTON IL
60202-1221
US

V. Phone/Fax

Practice location:
  • Phone: 773-386-3859
  • Fax:
Mailing address:
  • Phone: 773-386-3859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.009482
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: