Provider Demographics
NPI:1023408200
Name:JEREMIAH, ELIZABETH (MA, QMHP, LCPC, LPHA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:JEREMIAH
Suffix:
Gender:F
Credentials:MA, QMHP, LCPC, LPHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6432 HANCOCK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-2033
Mailing Address - Country:US
Mailing Address - Phone:618-303-7544
Mailing Address - Fax:618-206-8476
Practice Address - Street 1:1161 FORTUNE BLVD STE 400
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7385
Practice Address - Country:US
Practice Address - Phone:618-303-7544
Practice Address - Fax:618-206-8476
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-27
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009474101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health