Provider Demographics
NPI:1568147338
Name:POWELL, GINA E (MA)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:E
Last Name:POWELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 N WOOD ST APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-6563
Mailing Address - Country:US
Mailing Address - Phone:630-479-4348
Mailing Address - Fax:
Practice Address - Street 1:180 N MICHIGAN AVE STE 531
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7426
Practice Address - Country:US
Practice Address - Phone:847-508-1236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty