=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942822002
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANY M BRUTSMAN LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2020
-----------------------------------------------------
Last Update Date | 05/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4840 W BYRON ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60641-2778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-319-0238
-----------------------------------------------------
Fax | 773-282-7800
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1001 E TOUHY AVE STE 50
-----------------------------------------------------
City | DES PLAINES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60018-5817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-319-0238
-----------------------------------------------------
Fax | 773-282-7800
-----------------------------------------------------
=====================================================
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 | 149.021860
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------