=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700303450
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNE WILDMAN LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8641 W 75TH ST
-----------------------------------------------------
City | JUSTICE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-496-8716
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8641 W 75TH ST
-----------------------------------------------------
City | JUSTICE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60458-1114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-496-8722
-----------------------------------------------------
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 | 149020267
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041S0200X
-----------------------------------------------------
Taxonomy Name | School Social Worker
-----------------------------------------------------
License Number | 2322108
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------