Provider Demographics
NPI:1235669763
Name:BREMNER, ELIZABETH LASSANDRELLO
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:LASSANDRELLO
Last Name:BREMNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 W WASHINGTON ST STE 321
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-8297
Mailing Address - Country:US
Mailing Address - Phone:630-383-2077
Mailing Address - Fax:630-383-2076
Practice Address - Street 1:123 W. WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543
Practice Address - Country:US
Practice Address - Phone:630-383-2077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1001524101YS0200X
IL178011187101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool