Provider Demographics
NPI:1578898649
Name:ELECE DOUGLAS
Entity Type:Organization
Organization Name:ELECE DOUGLAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEVELOMENTAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ELECE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-335-3519
Mailing Address - Street 1:17309 HOLMES AVE
Mailing Address - Street 2:
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-1710
Mailing Address - Country:US
Mailing Address - Phone:708-335-3519
Mailing Address - Fax:708-335-3519
Practice Address - Street 1:17309 HOLMES AVE
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-1710
Practice Address - Country:US
Practice Address - Phone:708-335-3519
Practice Address - Fax:708-335-3519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-07
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities