Provider Demographics
NPI:1366455271
Name:WAYLAND-CRUIKSHANK, ALICE W (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ALICE
Middle Name:W
Last Name:WAYLAND-CRUIKSHANK
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 1:710 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:IL
Mailing Address - Zip Code:60093-1919
Mailing Address - Country:US
Mailing Address - Phone:847-446-8471
Mailing Address - Fax:847-446-8471
Practice Address - Street 1:1167 WILMETTE AVE
Practice Address - Street 2:SUITE #201
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2643
Practice Address - Country:US
Practice Address - Phone:847-251-7350
Practice Address - Fax:847-853-2600
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL947011Medicare ID - Type Unspecified