Healthcare Provider Details

I. General information

NPI: 1851041354
Provider Name (Legal Business Name): ELENI ISABEL KAITSON LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2022
Last Update Date: 03/27/2022
Certification Date: 03/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W SPRINGFIELD AVE STE 1201
CHAMPAIGN IL
61820-6385
US

IV. Provider business mailing address

201 W SPRINGFIELD AVE STE 1201
CHAMPAIGN IL
61820-6385
US

V. Phone/Fax

Practice location:
  • Phone: 217-722-9079
  • Fax: 217-501-4322
Mailing address:
  • Phone: 217-722-9079
  • Fax: 217-501-4322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150104780
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: