Provider Demographics
NPI:1285110064
Name:EARLY, MICHELE (SW)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:EARLY
Suffix:
Gender:F
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12612 S JUSTINE ST
Mailing Address - Street 2:
Mailing Address - City:CALUMET PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60827-6010
Mailing Address - Country:US
Mailing Address - Phone:773-849-1724
Mailing Address - Fax:
Practice Address - Street 1:12612 S JUSTINE ST
Practice Address - Street 2:
Practice Address - City:CALUMET PARK
Practice Address - State:IL
Practice Address - Zip Code:60827-6010
Practice Address - Country:US
Practice Address - Phone:773-849-1724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63152104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty