Provider Demographics
NPI:1013105600
Name:HANSEN, ELIZABETH (LCSW)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:HANSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:GARTNER
Other - Last Name:GOULD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1624 CARLYLE AVE # 503
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-4558
Mailing Address - Country:US
Mailing Address - Phone:404-723-9983
Mailing Address - Fax:
Practice Address - Street 1:1624 CARLYLE AVE # 503
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-4558
Practice Address - Country:US
Practice Address - Phone:404-723-9983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0038041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical