Healthcare Provider Details

I. General information

NPI: 1588056766
Provider Name (Legal Business Name): AUDREY DAMORE L.C.S.W., C.A.D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2015
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3809 MAGNOLIA DR
SPRING GROVE IL
60081-8631
US

IV. Provider business mailing address

3809 MAGNOLIA DR
SPRING GROVE IL
60081-8631
US

V. Phone/Fax

Practice location:
  • Phone: 612-741-1178
  • Fax:
Mailing address:
  • Phone: 612-741-1178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.020182
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: