Provider Demographics
NPI:1710227145
Name:BACCUS, ELLAMONIQUE
Entity Type:Individual
Prefix:
First Name:ELLAMONIQUE
Middle Name:
Last Name:BACCUS
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 1:15127 S 73RD AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-4398
Mailing Address - Country:US
Mailing Address - Phone:800-361-6880
Mailing Address - Fax:708-845-5505
Practice Address - Street 1:16107 LASALLE STREET
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473
Practice Address - Country:US
Practice Address - Phone:800-361-6880
Practice Address - Fax:708-845-5505
Is Sole Proprietor?:No
Enumeration Date:2013-02-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180007887101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional