Provider Demographics
NPI:1144337700
Name:WIGGINS, ELLEN AGNES (LCSW)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:AGNES
Last Name:WIGGINS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18154 MARTIN AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2139
Mailing Address - Country:US
Mailing Address - Phone:708-206-2755
Mailing Address - Fax:773-429-1841
Practice Address - Street 1:18154 MARTIN AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2139
Practice Address - Country:US
Practice Address - Phone:708-206-2755
Practice Address - Fax:773-429-1841
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical