Provider Demographics
NPI:1922324342
Name:ELLIOTT, AMANDA RAY (LCSW)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:RAY
Last Name:ELLIOTT
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 1:1211 EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016
Mailing Address - Country:US
Mailing Address - Phone:773-699-8868
Mailing Address - Fax:
Practice Address - Street 1:1580 N NORTHWEST HWY
Practice Address - Street 2:UNIT 215
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1444
Practice Address - Country:US
Practice Address - Phone:847-299-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-09
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL475Medicaid