Provider Demographics
NPI:1417169947
Name:COMBS, ELAINE B (DEVELOPMENTAL THERAP)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:B
Last Name:COMBS
Suffix:
Gender:F
Credentials:DEVELOPMENTAL THERAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 N 16TH ST
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-1219
Mailing Address - Country:US
Mailing Address - Phone:618-942-7481
Mailing Address - Fax:618-942-7481
Practice Address - Street 1:708 N 16TH ST
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-1219
Practice Address - Country:US
Practice Address - Phone:618-942-7481
Practice Address - Fax:618-942-7481
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILEC#56871199 P174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist