Provider Demographics
NPI:1699184846
Name:STEGALL, ELVINA
Entity Type:Individual
Prefix:
First Name:ELVINA
Middle Name:
Last Name:STEGALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15525 S PARK AVE STE 114
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-1380
Mailing Address - Country:US
Mailing Address - Phone:708-263-9512
Mailing Address - Fax:708-825-1244
Practice Address - Street 1:15525 S PARK AVE
Practice Address - Street 2:SUITE 114
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-1308
Practice Address - Country:US
Practice Address - Phone:708-263-9512
Practice Address - Fax:708-825-1244
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-12
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA58520002A261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder