Provider Demographics
NPI:1356070817
Name:ANDERSON, ELISABETH (NCSP)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 OAKBROOK DR
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-1584
Mailing Address - Country:US
Mailing Address - Phone:309-437-8524
Mailing Address - Fax:
Practice Address - Street 1:120 EASTGATE DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-9236
Practice Address - Country:US
Practice Address - Phone:309-423-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1006734103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1004796OtherNATIONAL ASSOCIATION OF SCHOOL PSYCHOLOGISTS
IL1006734OtherILLINOIS STATE BOARD OF EDUCATION