Healthcare Provider Details

I. General information

NPI: 1043053010
Provider Name (Legal Business Name): ELIZABETH R STEVENSON LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 06/17/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58500 S 6TH STREET
SPRINGFIELD IL
62703
US

IV. Provider business mailing address

5850 6TH STREET FRONTAGE RD E
SPRINGFIELD IL
62703-5162
US

V. Phone/Fax

Practice location:
  • Phone: 217-504-4027
  • Fax: 217-529-6154
Mailing address:
  • Phone: 217-504-4027
  • Fax: 217-529-6154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.108503
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: