Provider Demographics
NPI:1134215130
Name:SUKOWICZ, ELIZABETH A (PHD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:A
Last Name:SUKOWICZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 E SUMNER ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HARVARD
Mailing Address - State:IL
Mailing Address - Zip Code:60033-2840
Mailing Address - Country:US
Mailing Address - Phone:815-814-4193
Mailing Address - Fax:815-953-6540
Practice Address - Street 1:107 E SUMNER ST
Practice Address - Street 2:SUITE 1
Practice Address - City:HARVARD
Practice Address - State:IL
Practice Address - Zip Code:60033-2840
Practice Address - Country:US
Practice Address - Phone:815-814-4193
Practice Address - Fax:815-953-6540
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-006392103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK05921Medicare ID - Type Unspecified