Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | 149.014693 | IL |
NPI | 1003180266 |
---|---|
Provider Name | Elisa Terry |
First Address | Chicago, IL 60657-4811 |
Second Address | Chicago, IL 60657-4811 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/03/2012 |
Last Update Date | 05/03/2012 |