Provider Demographics
NPI:1093736092
Name:SHERACK, MINDY JO (LCSW)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:JO
Last Name:SHERACK
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:PO BOX 468
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60454-0468
Mailing Address - Country:US
Mailing Address - Phone:773-916-7107
Mailing Address - Fax:
Practice Address - Street 1:6006 159TH ST
Practice Address - Street 2:
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-2904
Practice Address - Country:US
Practice Address - Phone:773-916-7107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490091761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK20775Medicare ID - Type Unspecified