Provider Demographics
NPI:1154898922
Name:FRY, MICAH (LCSW)
Entity type:Individual
Prefix:MS
First Name:MICAH
Middle Name:
Last Name:FRY
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 1:1900 W POLK ST STE 154
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3723
Mailing Address - Country:US
Mailing Address - Phone:312-864-7599
Mailing Address - Fax:
Practice Address - Street 1:1900 W POLK ST STE 154
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3723
Practice Address - Country:US
Practice Address - Phone:312-864-7599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490192651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical