Provider Demographics
NPI:1114934726
Name:CALDWELL-MILLER, GABRIELLA CHANCE (MS, LPC, LCPC)
Entity Type:Individual
Prefix:MR
First Name:GABRIELLA
Middle Name:CHANCE
Last Name:CALDWELL-MILLER
Suffix:
Gender:F
Credentials:MS, LPC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 LINDA LN
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2397
Mailing Address - Country:US
Mailing Address - Phone:309-662-6134
Mailing Address - Fax:309-662-6302
Practice Address - Street 1:2416 E WASHINGTON ST
Practice Address - Street 2:SUITE A-1
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-4472
Practice Address - Country:US
Practice Address - Phone:309-662-6134
Practice Address - Fax:309-662-6302
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL509544Medicare UPIN
IL5732048Medicare UPIN
IL62-53657Medicare UPIN
IL226487Medicare UPIN