Basic Information
| Provider Information | |||||||||
| NPI: | 1689796401 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRAZILL | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | KATHLEEN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, ATR- BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCGOVERN | ||||||||
| OtherFirstName: | ERIN | ||||||||
| OtherMiddleName: | KATHLEEN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 611 W. PARK ST. | ||||||||
| Address2: | BWPC | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836792 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1813 W. KIRBY AVE | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618215410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173831850 | ||||||||
| FaxNumber: | 2173833439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 08/21/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149012478 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 4012 | OK | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | I.1100072 | OH | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1184775413 | 01 | IL | ORGANIZATIONAL NPI | OTHER |