Provider Demographics
NPI:1598175598
Name:BOLDEN-BAILEY, ELISE CARRIE (CADC)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:CARRIE
Last Name:BOLDEN-BAILEY
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3936 W ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60624-4389
Mailing Address - Country:US
Mailing Address - Phone:773-826-0398
Mailing Address - Fax:773-826-2327
Practice Address - Street 1:3936 W ROOSEVELT RD
Practice Address - Street 2:SUITE 2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624-4389
Practice Address - Country:US
Practice Address - Phone:773-826-0398
Practice Address - Fax:773-826-2327
Is Sole Proprietor?:No
Enumeration Date:2014-04-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL27812101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)