Provider Demographics
NPI:1740011022
Name:FILLMORE, ELIZABETH L
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:L
Last Name:FILLMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 CASS LN
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3045
Mailing Address - Country:US
Mailing Address - Phone:847-345-7295
Mailing Address - Fax:
Practice Address - Street 1:945 CASS LN
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3045
Practice Address - Country:US
Practice Address - Phone:847-345-7295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL12471706103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst