Provider Demographics
NPI:1548675382
Name:BLACK, ELIZABETH (MA, LCPC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 REVERE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-1566
Mailing Address - Country:US
Mailing Address - Phone:847-291-6805
Mailing Address - Fax:
Practice Address - Street 1:5 REVERE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1566
Practice Address - Country:US
Practice Address - Phone:847-291-6805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.009341101YM0800X
IL180010188101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health