Provider Demographics
NPI:1174297204
Name:GATTIS, ALICIA (LPC)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:GATTIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:
Other - Last Name:MORENO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2924 N KOLMAR AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-5205
Mailing Address - Country:US
Mailing Address - Phone:309-235-1378
Mailing Address - Fax:
Practice Address - Street 1:1767 W WILSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4516
Practice Address - Country:US
Practice Address - Phone:847-651-8643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178015640101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional