Healthcare Provider Details

I. General information

NPI: 1356070817
Provider Name (Legal Business Name): ELISABETH ANDERSON NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 EASTGATE DR
WASHINGTON IL
61571-9236
US

IV. Provider business mailing address

303 OAKBROOK DR
EAST PEORIA IL
61611-1584
US

V. Phone/Fax

Practice location:
  • Phone: 309-423-3111
  • Fax:
Mailing address:
  • Phone: 309-437-8524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1006734
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: