Provider Demographics
NPI:1073629143
Name:GORDON, DIANE TOBY (MSW)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:TOBY
Last Name:GORDON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 BELLEFORTE AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1303
Mailing Address - Country:US
Mailing Address - Phone:708-848-2983
Mailing Address - Fax:708-848-9922
Practice Address - Street 1:1017 BELLEFORTE AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1303
Practice Address - Country:US
Practice Address - Phone:708-848-2983
Practice Address - Fax:708-848-9922
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1671023OtherBLUE CROSS
IL1671023OtherBLUE CROSS