Provider Demographics
NPI:1417681388
Name:MAGNUS, GABRIELLE
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:MAGNUS
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 1:1705 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-2116
Mailing Address - Country:US
Mailing Address - Phone:630-747-1466
Mailing Address - Fax:
Practice Address - Street 1:2310 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1131
Practice Address - Country:US
Practice Address - Phone:312-213-5359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health