Provider Demographics
NPI:1053813592
Name:ZAGZEBSKI, GRETCHEN SELZER
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:SELZER
Last Name:ZAGZEBSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:LYNN
Other - Last Name:SELZER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3100 DUNDEE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2462
Mailing Address - Country:US
Mailing Address - Phone:847-313-9490
Mailing Address - Fax:
Practice Address - Street 1:3100 DUNDEE RD STE 101
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2462
Practice Address - Country:US
Practice Address - Phone:847-313-9490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-01
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.012166101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty