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General NPI Number Information
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NPI Number | 1669867289
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Entity Type | Individual
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Provider Name | BONNIE WADE L.C.S.W.
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Gender | Female
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Dates
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Enumeration Date | 03/31/2015
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Last Update Date | 09/14/2015
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Provider Practice Location Address
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Address Line | 10725 S WESTERN AVE 2ND FLOOR
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City | CHICAGO
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State | IL
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Zip | 60643-3135
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Country | US
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Telephone | 773-330-2544
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Fax |
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Provider Business Mailing Address
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Address Line | 1000 W DIVERSEY PKWY SUITE 275
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City | CHICAGO
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State | IL
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Zip | 60614-1879
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Country | US
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Telephone | 773-330-2544
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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 | 149.017407
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License Number State | IL
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