Provider Demographics
NPI:1659849222
Name:MARUYAMA, BLYTHE JUDITH HAMILTON (LCSW)
Entity type:Individual
Prefix:MS
First Name:BLYTHE
Middle Name:JUDITH HAMILTON
Last Name:MARUYAMA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:BLYTHE
Other - Middle Name:JUDITH
Other - Last Name:HAMILTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:529 S ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2812
Mailing Address - Country:US
Mailing Address - Phone:773-818-6570
Mailing Address - Fax:
Practice Address - Street 1:522 CHESTNUT ST STE 2D
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3173
Practice Address - Country:US
Practice Address - Phone:630-321-1073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490153711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty