MEDICARE: MIRA FRADKIN MSW, LSW

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
1	104100000X	Social Worker	150.113813	IL

General Provider Information

NPI Number	:	1669204145
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRA FRADKIN MSW, LSW

Provider Business Mailing Address
First Line	:	1206 W HENDERSON ST APT 2N
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1491
Country	:	US
Telephone Number	:	469-865-7816
Fax Number	:

Provider Business Practice Location Address
First Line	:	1206 W HENDERSON ST APT 2N
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1491
Country	:	US
Telephone Number	:	469-865-7816
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/14/2024
Last Update Date	:	12/16/2025

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