Basic Information
| Provider Information | |||||||||
| NPI: | 1649946039 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOTTLICK | ||||||||
| FirstName: | ELENA | ||||||||
| MiddleName: | ISADORA | ||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 522 W DIVERSEY PKWY APT 2N | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606141681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157427267 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1442 OLD SKOKIE VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600353032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477076744 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2021 | ||||||||
| LastUpdateDate: | 08/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 242.006550 | IL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.