Provider Demographics
NPI:1528656147
Name:ENERVOLD, MADELINE ROSE (LCSW)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:ROSE
Last Name:ENERVOLD
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:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:1401 LAKEWOOD DR STE A
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-3352
Practice Address - Country:US
Practice Address - Phone:815-942-6323
Practice Address - Fax:815-941-0308
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0239781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical