Provider Demographics
NPI:1861411357
Name:HARRISON, TODD FREDERICK (LCSW)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:FREDERICK
Last Name:HARRISON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 N FRANCISCO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-2609
Mailing Address - Country:US
Mailing Address - Phone:773-279-9795
Mailing Address - Fax:
Practice Address - Street 1:4740 N CLARK ST
Practice Address - Street 2:C/O C4
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4689
Practice Address - Country:US
Practice Address - Phone:773-769-0205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14900533OtherBLUE SHIELD
IL215445Medicare PIN
IL38870Medicare PIN