Provider Demographics
NPI:1346906120
Name:ROBERTS, GWENDOLYN DENISE
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:DENISE
Last Name:ROBERTS
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 1:3062 E 91ST ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-4401
Mailing Address - Country:US
Mailing Address - Phone:773-371-2988
Mailing Address - Fax:773-371-2950
Practice Address - Street 1:3062 E 91ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-4401
Practice Address - Country:US
Practice Address - Phone:773-371-2988
Practice Address - Fax:773-371-2950
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL362167940101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health