Provider Demographics
NPI:1619387800
Name:CZEMERYS WACKENHUT, ERIKA (LSW)
Entity type:Individual
Prefix:
First Name:ERIKA
Middle Name:
Last Name:CZEMERYS WACKENHUT
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:ERIKA
Other - Middle Name:
Other - Last Name:WACKENHUT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LSW
Mailing Address - Street 1:801 ANDERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-1248
Mailing Address - Country:US
Mailing Address - Phone:630-667-5193
Mailing Address - Fax:630-578-0949
Practice Address - Street 1:801 ANDERSON BLVD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-1248
Practice Address - Country:US
Practice Address - Phone:630-667-5193
Practice Address - Fax:630-578-0949
Is Sole Proprietor?:No
Enumeration Date:2014-04-28
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0167331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical