Provider Demographics
NPI:1578114872
Name:OSTLIE, BETH (ED S, NCSP)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:OSTLIE
Suffix:
Gender:F
Credentials:ED S, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1457 W LELAND AVE APT 2E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-7002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:403 ORCHARD ST
Practice Address - Street 2:
Practice Address - City:FOX RIVER GROVE
Practice Address - State:IL
Practice Address - Zip Code:60021-1145
Practice Address - Country:US
Practice Address - Phone:320-226-2269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2382047103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool