Healthcare Provider Details

I. General information

NPI: 1093406159
Provider Name (Legal Business Name): KEVIN OCKRIM LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2023
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 DAVIS ST
EVANSTON IL
60201-4619
US

IV. Provider business mailing address

1801 TOWER DR UNIT 218
GLENVIEW IL
60026-5824
US

V. Phone/Fax

Practice location:
  • Phone: 312-815-9660
  • Fax:
Mailing address:
  • Phone: 847-636-6254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number150.110484
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: