Healthcare Provider Details

I. General information

NPI: 1760726012
Provider Name (Legal Business Name): ANGELA JEAN FARRIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2948 ARTESIAN RD
NAPERVILLE IL
60564-8558
US

IV. Provider business mailing address

2948 ARTESIAN RD
NAPERVILLE IL
60564-8558
US

V. Phone/Fax

Practice location:
  • Phone: 630-428-7890
  • Fax: 630-428-7891
Mailing address:
  • Phone: 630-428-7890
  • Fax: 630-428-7891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2013005209
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149018739
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: