Provider Demographics
NPI:1093175762
Name:HEIDEMAN, ELIZABETH (LCSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:HEIDEMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1437 N SEDGWICK ST
Mailing Address - Street 2:APT. 2W
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-1269
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2525 W PETERSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-4108
Practice Address - Country:US
Practice Address - Phone:872-235-0880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0182431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical