Provider Demographics
NPI:1871628016
Name:WEEDEN, MARY R (RN, LCSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:R
Last Name:WEEDEN
Suffix:
Gender:F
Credentials:RN, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 323
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IL
Mailing Address - Zip Code:60071-0323
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 LAKE COOK RD
Practice Address - Street 2:SUITE 113
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-5646
Practice Address - Country:US
Practice Address - Phone:847-405-0220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0067271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical