1083031405 NPI number — MS. ELANA R DOR LSW, LCSW, TYPE 73

Table of content: MS. ELANA R DOR LSW, LCSW, TYPE 73 (NPI 1083031405)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083031405 NPI number — MS. ELANA R DOR LSW, LCSW, TYPE 73

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOR
Provider First Name:
ELANA
Provider Middle Name:
R
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LSW, LCSW, TYPE 73
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUBINSTEIN
Provider Other First Name:
ELANA
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083031405
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
540 W FRONTAGE RD
Provider Second Line Business Mailing Address:
SUITE 2135
Provider Business Mailing Address City Name:
NORTHFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60093-1250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-204-2043
Provider Business Mailing Address Fax Number:
847-236-0360

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
540 W FRONTAGE RD
Provider Second Line Business Practice Location Address:
SUITE 2135
Provider Business Practice Location Address City Name:
NORTHFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60093-1250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-204-2043
Provider Business Practice Location Address Fax Number:
847-236-0360
Provider Enumeration Date:
03/24/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  149.009455 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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