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General NPI Number Information
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NPI Number | 1912308453
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Entity Type | Organization
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Legal Business Name | CRIMSON LEADERSHIP GROUP
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Dates
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Enumeration Date | 09/15/2014
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Last Update Date | 09/15/2014
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Provider Practice Location Address
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Address Line | 3339 HIGHLAND AVE
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City | BERWYN
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State | IL
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Zip | 60402-3817
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Country | US
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Telephone | 630-248-9272
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Fax |
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Provider Business Mailing Address
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Address Line | 3339 HIGHLAND AVE APT/SUITE
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City | BERWYN
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State | IL
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Zip | 60402-3817
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Country | US
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Telephone | 630-248-9272
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | MRS. JOSETTE HEREDIA-CARMONA
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Credential | L.C.S.W
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Telephone | 630-248-9272
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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 | 149010344
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License Number State | IL
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