Provider Demographics
NPI:1174731871
Name:BEDEROW, LAURIE S (LCSW)
Entity type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:S
Last Name:BEDEROW
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5451 S HYDE PARK BLVD
Mailing Address - Street 2:2N
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-5801
Mailing Address - Country:US
Mailing Address - Phone:773-493-1148
Mailing Address - Fax:
Practice Address - Street 1:710 S PAULINA ST
Practice Address - Street 2:SUITE 731
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3808
Practice Address - Country:US
Practice Address - Phone:312-942-2066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL367840Medicare ID - Type UnspecifiedPART B