Healthcare Provider Details

I. General information

NPI: 1871414268
Provider Name (Legal Business Name): EBONY KAMILLE FRAZIER LICENSED SOCIAL WORK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14504 JOHN HUMPHREY DR
ORLAND PARK IL
60462-2640
US

IV. Provider business mailing address

14504 JOHN HUMPHREY DR
ORLAND PARK IL
60462-2640
US

V. Phone/Fax

Practice location:
  • Phone: 708-253-9392
  • Fax:
Mailing address:
  • Phone: 708-253-9392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150119064
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: