Basic Information
| Provider Information | |||||||||
| NPI: | 1811440563 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERCAW | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L.C.S.W | ||||||||
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| Mailing Information | |||||||||
| Address1: | 312 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605064637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306648876 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4840 W BYRON ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606412712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732827800 | ||||||||
| FaxNumber: | 7732822163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2016 | ||||||||
| LastUpdateDate: | 07/29/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149007040 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 149007040 | 01 | IL | STATE OF ILLINOIS DEPARTMENT OF HUMAN SERVICES | OTHER |