Provider Demographics
NPI:1669835856
Name:LIDOV, ELIZABETH (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:LIDOV
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-1351
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 W PHILLIP RD STE 108
Practice Address - Street 2:
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1730
Practice Address - Country:US
Practice Address - Phone:847-275-4115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-04
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146014621235Z00000X
CA10525235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist