Healthcare Provider Details

I. General information

NPI: 1821771908
Provider Name (Legal Business Name): ELIZABETH STASIK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2023
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2132 BRUMMEL ST
EVANSTON IL
60202-3608
US

IV. Provider business mailing address

2132 BRUMMEL ST
EVANSTON IL
60202-3608
US

V. Phone/Fax

Practice location:
  • Phone: 330-298-5447
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149022420
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: