Provider Demographics
NPI:1356075121
Name:CHAN, ELIZABETH S
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:S
Last Name:CHAN
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 1:920 W SHERIDAN RD APT 203
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-5054
Mailing Address - Country:US
Mailing Address - Phone:224-217-8637
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST STE 440
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3836
Practice Address - Country:US
Practice Address - Phone:312-563-2454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.014560225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist