Provider Demographics
NPI:1609105568
Name:MEDINA, IRENE (MSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:IRENE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17W727 BUTTERFIELD RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:OAKBROOK TERRACE
Mailing Address - State:IL
Mailing Address - Zip Code:60181-4278
Mailing Address - Country:US
Mailing Address - Phone:773-802-3618
Mailing Address - Fax:
Practice Address - Street 1:17W727 BUTTERFIELD RD
Practice Address - Street 2:SUITE E
Practice Address - City:OAKBROOK TERRACE
Practice Address - State:IL
Practice Address - Zip Code:60181-4278
Practice Address - Country:US
Practice Address - Phone:773-802-3618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-23
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490157121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400100304Medicare PIN