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General NPI Number Information
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NPI Number | 1104135029
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Entity Type | Individual
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Provider Name | IVAN CECIL JAMES IV MSW
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Gender | Male
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Dates
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Enumeration Date | 09/27/2010
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Last Update Date | 01/23/2026
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Provider Practice Location Address
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Address Line | 8023 S INDIANA AVE APT 2
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City | CHICAGO
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State | IL
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Zip | 60619-3506
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Country | US
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Telephone | 773-317-4900
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Fax |
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Provider Business Mailing Address
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Address Line | 5644 S OAKLEY AVE
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City | CHICAGO
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State | IL
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Zip | 60636-1025
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Country | US
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Telephone | 773-317-4900
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149027003
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License Number State | IL
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