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General NPI Number Information
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NPI Number | 1164886297
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Entity Type | Organization
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Legal Business Name | FORTYTHIRTYONE, INC
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Dates
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Enumeration Date | 04/05/2016
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Last Update Date | 04/05/2016
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Provider Practice Location Address
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Address Line | 1580 N NORTHWEST HWY SUITE 312
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City | PARK RIDGE
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State | IL
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Zip | 60068-1444
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Country | US
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Telephone | 847-827-0600
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Fax | 877-481-0769
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Provider Business Mailing Address
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Address Line | 1580 N NORTHWEST HWY SUITE 312
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City | PARK RIDGE
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State | IL
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Zip | 60068-1444
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Country | US
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Telephone | 847-827-0600
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Fax | 877-481-0769
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Authorized Official
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Title or Position | PRESIDENT
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Name | MS. NADA MARIE BRZOVICH
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Credential | LCSW
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Telephone | 847-827-0600
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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 | 149010861
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License Number State | IL
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