Healthcare Provider Details

I. General information

NPI: 1750644431
Provider Name (Legal Business Name): AUGUSTINE SOHN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4710 LINCOLN HWY 321
MATTESON IL
60443-2316
US

IV. Provider business mailing address

612 HARRISON ST
OAK PARK IL
60304-1358
US

V. Phone/Fax

Practice location:
  • Phone: 773-420-3481
  • Fax: 773-420-3597
Mailing address:
  • Phone: 708-215-1676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149014253
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: