=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689343147
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER FLETT MA, LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2021
-----------------------------------------------------
Last Update Date | 09/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4001 N BROADWAY ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60613-2110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-510-1782
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1937 W SCHILLER ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60622-1913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-510-1782
-----------------------------------------------------
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 | 149009134
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------