Provider Demographics
NPI:1376100735
Name:GERSHUN, NICOLE EILEEN (MS, CFY)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:EILEEN
Last Name:GERSHUN
Suffix:
Gender:F
Credentials:MS, CFY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 W POTOMAC AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3153
Mailing Address - Country:US
Mailing Address - Phone:630-456-5476
Mailing Address - Fax:
Practice Address - Street 1:2005 W POTOMAC AVE APT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-3153
Practice Address - Country:US
Practice Address - Phone:630-456-5476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty