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NPI Code Detail

MEDICARE: ELISE CARRIE BOLDEN-BAILEY CADC

MEDICARE: ELISE CARRIE BOLDEN-BAILEY CADC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YA0400XAddiction (Substance Use Disorder) Counselor27812IL

General Provider Information

NPI Number : 1598175598
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELISE CARRIE BOLDEN-BAILEY CADC
Provider Business Mailing Address
First Line : 3936 W ROOSEVELT RD
Second Line :
City : CHICAGO
State : IL
Zip : 60624-4389
Country : US
Telephone Number : 773-826-0398
Fax Number : 773-826-2327
Provider Business Practice Location Address
First Line : 3936 W ROOSEVELT RD
Second Line : SUITE 2
City : CHICAGO
State : IL
Zip : 60624-4389
Country : US
Telephone Number : 773-826-0398
Fax Number : 773-826-2327
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/30/2014
Last Update Date : 04/30/2014

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