Provider Demographics
NPI:1942352018
Name:ELLIOTT, ESMARIE
Entity Type:Individual
Prefix:MISS
First Name:ESMARIE
Middle Name:
Last Name:ELLIOTT
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 1:14518 S WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60827-2844
Mailing Address - Country:US
Mailing Address - Phone:708-841-6240
Mailing Address - Fax:708-880-1138
Practice Address - Street 1:6121 S SANGAMON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-2003
Practice Address - Country:US
Practice Address - Phone:773-488-7251
Practice Address - Fax:773-488-7258
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180003629101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional