Provider Demographics
NPI:1104116789
Name:BURTON, STACI LATRICE (MSW, LSW)
Entity type:Individual
Prefix:MS
First Name:STACI
Middle Name:LATRICE
Last Name:BURTON
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 N STATE ST
Mailing Address - Street 2:SUITE 1300
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3315
Mailing Address - Country:US
Mailing Address - Phone:312-939-8622
Mailing Address - Fax:312-939-0391
Practice Address - Street 1:17 N STATE ST
Practice Address - Street 2:SUITE 1300
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3315
Practice Address - Country:US
Practice Address - Phone:312-939-8622
Practice Address - Fax:312-939-0391
Is Sole Proprietor?:No
Enumeration Date:2011-04-15
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.011744104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker