Healthcare Provider Details

I. General information

NPI: 1295349538
Provider Name (Legal Business Name): ANGELIQUE BIANCA WHITE-MILLWOOD MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2020
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 S ADDISON AVE
VILLA PARK IL
60181-2877
US

IV. Provider business mailing address

120 S MARION ST
OAK PARK IL
60302-2809
US

V. Phone/Fax

Practice location:
  • Phone: 630-620-4433
  • Fax:
Mailing address:
  • Phone: 708-383-7500
  • Fax: 708-383-7780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.024805
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: