Healthcare Provider Details

I. General information

NPI: 1558716407
Provider Name (Legal Business Name): BRANDY ELMORE MA, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 12/11/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 E WASHINGTON ST, STE 2F
BLOOMINGTON IL
61701-4365
US

IV. Provider business mailing address

2103 E WASHINGTON ST, STE 2F
BLOOMINGTON IL
61701-4365
US

V. Phone/Fax

Practice location:
  • Phone: 217-377-0546
  • Fax:
Mailing address:
  • Phone: 217-377-0546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number2429459
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.026242
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: