Healthcare Provider Details

I. General information

NPI: 1578705356
Provider Name (Legal Business Name): DENISE R. EAVES LCSW, CEAP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2009
Last Update Date: 04/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 N GREENLEAF ST 200
GURNEE IL
60031-3393
US

IV. Provider business mailing address

34159 N. HAINESVILLE ROAD
ROUND LAKE IL
60073-9790
US

V. Phone/Fax

Practice location:
  • Phone: 847-637-5239
  • Fax: 847-637-5239
Mailing address:
  • Phone: 847-543-7778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149001691
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: