Provider Demographics
NPI:1154087880
Name:CZAJA, GABRIELLE
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:CZAJA
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 1:629 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-2733
Mailing Address - Country:US
Mailing Address - Phone:815-721-0145
Mailing Address - Fax:
Practice Address - Street 1:301 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-1012
Practice Address - Country:US
Practice Address - Phone:815-201-1970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.08224331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical