Basic Information
Provider Information | |||||||||
NPI: | 1063925527 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BREW | ||||||||
FirstName: | CASEY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, CGC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 603 LONGACRE LN | ||||||||
Address2: |   | ||||||||
City: | ISLAND LAKE | ||||||||
State: | IL | ||||||||
PostalCode: | 600429681 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8472171021 | ||||||||
FaxNumber: | 3129422857 | ||||||||
Practice Location | |||||||||
Address1: | 1725 W. HARRISON | ||||||||
Address2: | SUITE 710 | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 60612 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3129423034 | ||||||||
FaxNumber: | 3129422857 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/07/2017 | ||||||||
LastUpdateDate: | 11/07/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 170300000X | 246.000330 | IL | Y |   | Other Service Providers | Genetic Counselor, MS |   |
No ID Information.