=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245693027
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEPHANIE ARDAGH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2016
-----------------------------------------------------
Last Update Date | 03/30/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1020 N. MILWAUKEE AVE SUITE 242
-----------------------------------------------------
City | DEERFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-475-3990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1461 PAULINE CIR
-----------------------------------------------------
City | MUNDELEIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60060-4124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | STEPHANIE ARDAGH
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 847-331-2145
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------