Healthcare Provider Details

I. General information

NPI: 1053072975
Provider Name (Legal Business Name): LA JUAN BAINES MSW,LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2022
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27475 FERRY RD
WARRENVILLE IL
60555-3808
US

IV. Provider business mailing address

27475 FERRY RD
WARRENVILLE IL
60555-3808
US

V. Phone/Fax

Practice location:
  • Phone: 312-671-0088
  • Fax:
Mailing address:
  • Phone: 312-671-0088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150108836
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.027477
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: