Healthcare Provider Details

I. General information

NPI: 1760112999
Provider Name (Legal Business Name): CORY NAM LU LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2022
Last Update Date: 06/11/2022
Certification Date: 06/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

778 W FRONTAGE RD STE 113
NORTHFIELD IL
60093-1209
US

IV. Provider business mailing address

5556 N SHERIDAN RD APT 611
CHICAGO IL
60640-1677
US

V. Phone/Fax

Practice location:
  • Phone: 612-804-7038
  • Fax:
Mailing address:
  • Phone: 612-804-7038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number150.106068
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number150.106068
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: