=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134778152
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT W HEALY LSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2019
-----------------------------------------------------
Last Update Date | 09/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1325 N HIGHLAND AVE
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60506-1449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-801-2633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16217 S MCGRATH DR
-----------------------------------------------------
City | PLAINFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60586-9043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-740-8841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 150.103896
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------