Provider Demographics
NPI:1679700025
Name:BASMENJI, MARYAM (LCSW)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:BASMENJI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E WATERSIDE DR
Mailing Address - Street 2:UNIT 610
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-8001
Mailing Address - Country:US
Mailing Address - Phone:801-580-9673
Mailing Address - Fax:
Practice Address - Street 1:10 E ONTARIO ST
Practice Address - Street 2:2008
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2736
Practice Address - Country:US
Practice Address - Phone:801-580-9673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-12
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490139661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical