=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265044812
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY M CREAMER LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2020
-----------------------------------------------------
Last Update Date | 08/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4314 S COTTAGE GROVE AVE RM 208
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60653-3514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-933-5741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5201 S CALUMET AVE APT 3R
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60615-3542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-933-5741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149.013054
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------