Healthcare Provider Details

I. General information

NPI: 1588458590
Provider Name (Legal Business Name): ELLIANA BRODY
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 09/20/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 ACADEMY DR
NORTHBROOK IL
60062-2421
US

IV. Provider business mailing address

614 ACADEMY DR
NORTHBROOK IL
60062-2421
US

V. Phone/Fax

Practice location:
  • Phone: 847-769-4500
  • Fax:
Mailing address:
  • Phone: 847-769-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.033097
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.529434
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: