Provider Demographics
NPI:1487902185
Name:LABASH, AMANDA KAITLYN (LCSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:KAITLYN
Last Name:LABASH
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 1:17W728 BUTTERFIELD RD
Mailing Address - Street 2:#113
Mailing Address - City:OAKBROOK TERRACE
Mailing Address - State:IL
Mailing Address - Zip Code:60181-4251
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16410 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452
Practice Address - Country:US
Practice Address - Phone:708-960-4023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490145591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149014559OtherLICENSED CLINICAL SOCIAL WORKER MASTERS LICENSE