Provider Demographics
NPI:1154614634
Name:WALDEN, JULIET ANN RUSSOM (BS, AM, LSCW)
Entity type:Individual
Prefix:MS
First Name:JULIET
Middle Name:ANN RUSSOM
Last Name:WALDEN
Suffix:
Gender:F
Credentials:BS, AM, LSCW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 W 22ND PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-4205
Mailing Address - Country:US
Mailing Address - Phone:773-247-6689
Mailing Address - Fax:
Practice Address - Street 1:13136 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2423
Practice Address - Country:US
Practice Address - Phone:708-974-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0143051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical