=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063078533
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAROL CONNELL LCSW PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2019
-----------------------------------------------------
Last Update Date | 04/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 53 W JACKSON BLVD STE 626
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60604-3444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-560-6653
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1634 FOREST AVE
-----------------------------------------------------
City | WILMETTE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60091-1530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CAROL CONNELL
-----------------------------------------------------
Credential | LCSW PLLC
-----------------------------------------------------
Telephone | 847-612-9570
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------