Basic Information
| Provider Information | |||||||||
| NPI: | 1700129251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENDIX | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L.C.S.W. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2015 N DAMEN AVE | ||||||||
| Address2: | APT. 1R | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606474548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482291198 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 25650 OUTER DR | ||||||||
| Address2: | |||||||||
| City: | LINCOLN PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481462096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133831897 | ||||||||
| FaxNumber: | 3133836018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2013 | ||||||||
| LastUpdateDate: | 12/17/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149015716 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0962301 | 01 | MI | BCBSM | OTHER |