Provider Demographics
NPI:1720208762
Name:BROWN, ELSIE (CDS)
Entity Type:Individual
Prefix:
First Name:ELSIE
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:CDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 548
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-0548
Mailing Address - Country:US
Mailing Address - Phone:618-922-8320
Mailing Address - Fax:618-998-5883
Practice Address - Street 1:801 W BOULEVARD ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1737
Practice Address - Country:US
Practice Address - Phone:618-922-8320
Practice Address - Fax:618-998-5883
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILEB20880999P174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILEB20880999POtherEVALUATOR CREDENTIAL