Provider Demographics
NPI:1013032192
Name:STANISLAUS, CONNIE S (LCSW)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:S
Last Name:STANISLAUS
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 1:114 W ROCKLAND RD
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60060
Mailing Address - Country:US
Mailing Address - Phone:847-816-9180
Mailing Address - Fax:847-816-9183
Practice Address - Street 1:114 W ROCKLAND RD
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60060
Practice Address - Country:US
Practice Address - Phone:847-816-9180
Practice Address - Fax:847-816-9183
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1295897148OtherNATIONAL ID GROUP