Provider Demographics
NPI:1588254411
Name:DAVYDENKOVAS, BAIBA (LSW)
Entity type:Individual
Prefix:
First Name:BAIBA
Middle Name:
Last Name:DAVYDENKOVAS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10001 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60131-2563
Mailing Address - Country:US
Mailing Address - Phone:847-461-0330
Mailing Address - Fax:
Practice Address - Street 1:12243 S 69TH AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1623
Practice Address - Country:US
Practice Address - Phone:708-738-6712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.107882104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILNONEMedicaid