Provider Demographics
NPI:1467093807
Name:GROSSMAN, GAIL
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:
Last Name:GROSSMAN
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 1:713 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-2310
Mailing Address - Country:US
Mailing Address - Phone:847-733-8302
Mailing Address - Fax:
Practice Address - Street 1:713 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-2310
Practice Address - Country:US
Practice Address - Phone:847-733-8302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILNONEMedicaid