Provider Demographics
NPI:1003180266
Name:TERRY, ELISA (LCSW)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:TERRY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 N SHERIDAN RD
Mailing Address - Street 2:#22A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-4811
Mailing Address - Country:US
Mailing Address - Phone:773-327-9161
Mailing Address - Fax:
Practice Address - Street 1:3150 N SHERIDAN RD
Practice Address - Street 2:#22A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-4811
Practice Address - Country:US
Practice Address - Phone:773-327-9161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0146931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical