Healthcare Provider Details

I. General information

NPI: 1265938104
Provider Name (Legal Business Name): AMY ALLYSSA DEEGAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2018
Last Update Date: 03/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7627 LAKE ST STE 217
RIVER FOREST IL
60305-1878
US

IV. Provider business mailing address

8111 ROUTE 53 APT 23
WOODRIDGE IL
60517-3609
US

V. Phone/Fax

Practice location:
  • Phone: 630-740-4768
  • Fax:
Mailing address:
  • Phone: 630-740-4768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.019889
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: