Provider Demographics
NPI:1457620817
Name:ELEY, MEREDITH BENTON (LSAA)
Entity type:Individual
Prefix:
First Name:MEREDITH
Middle Name:BENTON
Last Name:ELEY
Suffix:
Gender:F
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-6819
Mailing Address - Country:US
Mailing Address - Phone:847-686-4444
Mailing Address - Fax:847-686-9999
Practice Address - Street 1:105 PASEO DEL CANON W STE A
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6943
Practice Address - Country:US
Practice Address - Phone:575-737-5533
Practice Address - Fax:575-737-5534
Is Sole Proprietor?:No
Enumeration Date:2011-12-14
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005585133V00000X
NMCTB-2023-0614101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered