Healthcare Provider Details

I. General information

NPI: 1215596887
Provider Name (Legal Business Name): VIVIANE NGWA MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 06/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4747 LINCOLN MALL DR STE 101
MATTESON IL
60443-3812
US

IV. Provider business mailing address

4747 LINCOLN MALL DR STE 101
MATTESON IL
60443-3812
US

V. Phone/Fax

Practice location:
  • Phone: 708-747-2655
  • Fax: 708-747-2859
Mailing address:
  • Phone: 312-758-2157
  • Fax: 708-747-2859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149007250
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: