Provider Demographics
NPI:1427933043
Name:WHITE, MARY KATHLEEN (LSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:WHITE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 N WINCHESTER AVE APT CH2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1368
Mailing Address - Country:US
Mailing Address - Phone:317-446-3119
Mailing Address - Fax:
Practice Address - Street 1:2334 W LAWRENCE AVE STE 201
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-1046
Practice Address - Country:US
Practice Address - Phone:773-756-1733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-11
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.117115104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty