Provider Demographics
NPI:1245623073
Name:REYNOLDS, ELIZABETH
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LIZ
Other - Middle Name:
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:444 E ROOSEVELT RD # 131
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-4630
Mailing Address - Country:US
Mailing Address - Phone:630-981-7718
Mailing Address - Fax:
Practice Address - Street 1:413 S 3RD ST
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-3103
Practice Address - Country:US
Practice Address - Phone:630-981-7718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-18
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149011980101YM0800X
IL149.011908101YM0800X, 1041C0700X
IL1490119081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health