1669661872 NPI number — ELIZABETH JEAN WILTON MA, LCPC

Table of content: ELIZABETH JEAN WILTON MA, LCPC (NPI 1669661872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669661872 NPI number — ELIZABETH JEAN WILTON MA, LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILTON
Provider First Name:
ELIZABETH
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669661872
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
11/30/2018
NPI Reactivation Date:
02/19/2019

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7523 N CLAREMONT AVE
Provider Second Line Business Mailing Address:
UNIT G
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60645-1514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-396-8607
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2526 N LINCOLN AVE
Provider Second Line Business Practice Location Address:
SUITE 218
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60614-2353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-574-7574
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/24/2007

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: 101YP2500X , with the licence number:  180006152 , 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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