Provider Demographics
NPI:1275810202
Name:BLUMENTHAL, ELLEN R (LCSW)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:R
Last Name:BLUMENTHAL
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 1:435 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:IL
Mailing Address - Zip Code:60022-1845
Mailing Address - Country:US
Mailing Address - Phone:847-707-2135
Mailing Address - Fax:
Practice Address - Street 1:435 GROVE ST
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:IL
Practice Address - Zip Code:60022-1845
Practice Address - Country:US
Practice Address - Phone:847-707-2135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-04
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150-003336104100000X
IL149.0198091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker