Provider Demographics
NPI:1659113363
Name:BREKELBAUM, ELIZABETH G (LCPC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:G
Last Name:BREKELBAUM
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4582 CINNAMON LN
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-5326
Mailing Address - Country:US
Mailing Address - Phone:815-979-1195
Mailing Address - Fax:
Practice Address - Street 1:6723 WEAVER RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-8021
Practice Address - Country:US
Practice Address - Phone:815-242-1213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.016116101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health