Provider Demographics
NPI:1629119268
Name:ERICSSON, EVA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:EVA
Middle Name:
Last Name:ERICSSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6310 TREMONT ST
Mailing Address - Street 2:
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5476
Mailing Address - Country:US
Mailing Address - Phone:630-887-9733
Mailing Address - Fax:630-887-9776
Practice Address - Street 1:112 S GRANT ST
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-4051
Practice Address - Country:US
Practice Address - Phone:630-850-7739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL409950Medicare ID - Type Unspecified