Provider Demographics
NPI:1548782642
Name:WILBOURNE, AMY JOHNSON (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:JOHNSON
Last Name:WILBOURNE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 LYMAN AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-1613
Mailing Address - Country:US
Mailing Address - Phone:312-857-8670
Mailing Address - Fax:
Practice Address - Street 1:30 N MICHIGAN AVE STE 1528
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3600
Practice Address - Country:US
Practice Address - Phone:312-857-8670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-10
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490166811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical