Healthcare Provider Details

I. General information

NPI: 1912550773
Provider Name (Legal Business Name): EEVON SWILLEY LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2019
Last Update Date: 01/10/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25480 W CEDAR CREST LN
LAKE VILLA IL
60046-8256
US

IV. Provider business mailing address

55 E JACKSON BLVD STE 1500
CHICAGO IL
60604-4137
US

V. Phone/Fax

Practice location:
  • Phone: 847-356-8205
  • Fax:
Mailing address:
  • Phone: 312-663-1130
  • Fax: 312-663-0504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number150103770
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150103770
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number149022661
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: