Provider Demographics
NPI:1164539326
Name:GOLD, RACHELLE (PSYD)
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:
Last Name:GOLD
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 W PETERSON AVE
Mailing Address - Street 2:STE. 612
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-5713
Mailing Address - Country:US
Mailing Address - Phone:773-338-6976
Mailing Address - Fax:773-338-6976
Practice Address - Street 1:7101 N. CICERO AVE.
Practice Address - Street 2:SUITE 203
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-2112
Practice Address - Country:US
Practice Address - Phone:773-991-7224
Practice Address - Fax:773-338-6976
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006126103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1632418OtherBLUE CROSS BLUE SHIELD
201657Medicare UPIN