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NPI Code Detail

MEDICARE: COKETHA SAMYRA JEAN HENDRICKS LCSW

MEDICARE: COKETHA SAMYRA JEAN HENDRICKS LCSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker149019293IL

General Provider Information

NPI Number : 1215553557
Entity Type Code : Individual
Provider Name (Legal Business Name) : COKETHA SAMYRA JEAN HENDRICKS LCSW
Provider Business Mailing Address
First Line : 2627 W CERMAK RD
Second Line :
City : CHICAGO
State : IL
Zip : 60608-3514
Country : US
Telephone Number : 312-413-3282
Fax Number :
Provider Business Practice Location Address
First Line : 2627 W CERMAK RD
Second Line :
City : CHICAGO
State : IL
Zip : 60608-3514
Country : US
Telephone Number : 312-413-3282
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/23/2020
Last Update Date : 06/02/2025

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