Healthcare Provider Details

I. General information

NPI: 1013482736
Provider Name (Legal Business Name): ELISSA WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2018
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 W FULLERTON AVE
CHICAGO IL
60647-2319
US

IV. Provider business mailing address

3600 W FULLERTON AVE
CHICAGO IL
60647-2319
US

V. Phone/Fax

Practice location:
  • Phone: 773-782-2800
  • Fax:
Mailing address:
  • Phone: 773-782-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149025522
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: