Healthcare Provider Details

I. General information

NPI: 1235669763
Provider Name (Legal Business Name): ELIZABETH LASSANDRELLO BREMNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2017
Last Update Date: 06/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 W. WASHINGTON ST
OSWEGO IL
60543
US

IV. Provider business mailing address

123 W WASHINGTON ST STE 321
OSWEGO IL
60543-8297
US

V. Phone/Fax

Practice location:
  • Phone: 630-383-2077
  • Fax:
Mailing address:
  • Phone: 630-383-2077
  • Fax: 630-383-2076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178011187
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number1001524
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: