=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043595218
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. ANDREA ELIZABETH FREERKSEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2011
-----------------------------------------------------
Last Update Date | 03/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1525 E 53RD ST STE 503
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60615-4530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-542-3493
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3445 S RHODES AVE APT 204
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60616-4252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-542-3493
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------