Healthcare Provider Details

I. General information

NPI: 1336652379
Provider Name (Legal Business Name): ERIN STALEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ERIN HAGAN LSW

II. Dates (important events)

Enumeration Date: 11/13/2017
Last Update Date: 11/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W 5TH AVE STE 205
NAPERVILLE IL
60563-4945
US

IV. Provider business mailing address

2221 COVINGTON LN
PLAINFIELD IL
60586-5519
US

V. Phone/Fax

Practice location:
  • Phone: 630-779-0751
  • Fax:
Mailing address:
  • Phone: 847-207-4680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149016631
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: