Provider Demographics
NPI:1336980705
Name:GILLETTE, ELIZABETH
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:GILLETTE
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 1:1401 E HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-2551
Mailing Address - Country:US
Mailing Address - Phone:815-510-1069
Mailing Address - Fax:
Practice Address - Street 1:401 W BRIDGE ST
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-2705
Practice Address - Country:US
Practice Address - Phone:815-310-5779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-01
Last Update Date:2024-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach