Provider Demographics
NPI:1417100991
Name:BLAINE, GERSHENZON, AND HEINS
Entity Type:Organization
Organization Name:BLAINE, GERSHENZON, AND HEINS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:GERSHENZON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW AND MA
Authorized Official - Phone:847-480-9671
Mailing Address - Street 1:3411 VANTAGE LN
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-1366
Mailing Address - Country:US
Mailing Address - Phone:847-480-9671
Mailing Address - Fax:312-372-0607
Practice Address - Street 1:3411 VANTAGE LN
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1366
Practice Address - Country:US
Practice Address - Phone:847-480-9671
Practice Address - Fax:312-372-0607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.003586103TC0700X
ILLCSW1490052791041C0700X
ILLCSW1490001971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty