Provider Demographics
NPI:1225123706
Name:STATEN BRABHAM, GINA M (MA, LCPC)
Entity Type:Individual
Prefix:MS
First Name:GINA
Middle Name:M
Last Name:STATEN BRABHAM
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7003 SIERRA CT.
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:IL
Mailing Address - Zip Code:60561
Mailing Address - Country:US
Mailing Address - Phone:708-354-0826
Mailing Address - Fax:708-354-0867
Practice Address - Street 1:1023 BURLINGTON AVE.
Practice Address - Street 2:
Practice Address - City:WESTERN SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60558
Practice Address - Country:US
Practice Address - Phone:708-354-0826
Practice Address - Fax:708-354-0867
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional