Provider Demographics
NPI:1578781720
Name:GOMBERG, MICHELLE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:GOMBERG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:GOMBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:11 S 2ND AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1941
Mailing Address - Country:US
Mailing Address - Phone:630-465-1921
Mailing Address - Fax:
Practice Address - Street 1:11 S 2ND AVE STE 5
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1941
Practice Address - Country:US
Practice Address - Phone:630-465-1921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490123261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical