Provider Demographics
NPI:1730732975
Name:BOTHWELL, GRACE (MSW)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:BOTHWELL
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1459 N BOSWORTH AVE APT 1R
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-7014
Mailing Address - Country:US
Mailing Address - Phone:608-359-6729
Mailing Address - Fax:
Practice Address - Street 1:1459 N BOSWORTH AVE APT 1R
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-7014
Practice Address - Country:US
Practice Address - Phone:608-359-6729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
IL150.109277101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician