=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942930177
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTONIA WARREN LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2022
-----------------------------------------------------
Last Update Date | 06/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 778 W FRONTAGE RD STE 113
-----------------------------------------------------
City | NORTHFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60093-1209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-267-5716
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 W MAPLE ST APT 2508
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60610-5457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-267-5716
-----------------------------------------------------
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 | 149023042
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------