Provider Demographics
NPI:1154378081
Name:DOUGLAS, ELIZABETH ANN (MSW)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANN
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6648 N NEWGARD AVE
Mailing Address - Street 2:#2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-4712
Mailing Address - Country:US
Mailing Address - Phone:773-381-2350
Mailing Address - Fax:
Practice Address - Street 1:ROOSEVELT &5TH AVE.
Practice Address - Street 2:
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141
Practice Address - Country:US
Practice Address - Phone:708-202-3639
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical