Provider Demographics
NPI:1285068767
Name:GILBERT, ELLEN MARIE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:MARIE
Last Name:GILBERT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:ELLEN
Other - Middle Name:MARIE
Other - Last Name:SURPRENANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:210 AVENUE C
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-5410
Mailing Address - Country:US
Mailing Address - Phone:217-442-3200
Mailing Address - Fax:217-442-7460
Practice Address - Street 1:210 AVENUE C
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-5410
Practice Address - Country:US
Practice Address - Phone:217-442-3200
Practice Address - Fax:217-442-7460
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490181451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400293122Medicare PIN