Provider Demographics
NPI:1558716407
Name:ELMORE, BRANDY (MA, LCSW)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:ELMORE
Suffix:
Gender:F
Credentials:MA, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 E WASHINGTON ST, STE 2F
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4365
Mailing Address - Country:US
Mailing Address - Phone:217-377-0546
Mailing Address - Fax:
Practice Address - Street 1:2103 E WASHINGTON ST, STE 2F
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4365
Practice Address - Country:US
Practice Address - Phone:217-377-0546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-28
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL24294591041S0200X
IL149.0262421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool