Provider Demographics
NPI:1730763228
Name:ILLIDGE, LESLIE JOEL
Entity type:Individual
Prefix:MR
First Name:LESLIE
Middle Name:JOEL
Last Name:ILLIDGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8530 S SAINT LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-6025
Mailing Address - Country:US
Mailing Address - Phone:773-852-0642
Mailing Address - Fax:
Practice Address - Street 1:8530 S SAINT LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-6025
Practice Address - Country:US
Practice Address - Phone:773-852-0642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150007727104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker