Healthcare Provider Details

I. General information

NPI: 1023633534
Provider Name (Legal Business Name): ELIZABETH M RENDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 WESTWARD DR
SPRING GROVE IL
60081-8888
US

IV. Provider business mailing address

12304 304TH AVE
TREVOR WI
53179-9766
US

V. Phone/Fax

Practice location:
  • Phone: 847-445-0023
  • Fax:
Mailing address:
  • Phone: 847-613-0647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149017075
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: