Provider Demographics
NPI:1093402984
Name:GAUMER, KAILEEN BANASZAK
Entity Type:Individual
Prefix:
First Name:KAILEEN
Middle Name:BANASZAK
Last Name:GAUMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 CRESTVIEW RD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:61081-4314
Mailing Address - Country:US
Mailing Address - Phone:630-781-6207
Mailing Address - Fax:
Practice Address - Street 1:629 N GALENA AVE STE 120
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-1664
Practice Address - Country:US
Practice Address - Phone:815-288-1235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.005831101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional