Provider Demographics
NPI:1851824304
Name:GUSTAFSSON ELDEIRY, LILI-ANN (LSW)
Entity Type:Individual
Prefix:
First Name:LILI-ANN
Middle Name:
Last Name:GUSTAFSSON ELDEIRY
Suffix:
Gender:M
Credentials:LSW
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 245
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-0245
Mailing Address - Country:US
Mailing Address - Phone:847-960-3635
Mailing Address - Fax:
Practice Address - Street 1:1140 N MCLEAN BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-1782
Practice Address - Country:US
Practice Address - Phone:847-695-3680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.014142104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker