Provider Demographics
NPI:1629239439
Name:SELDESS, GABRIEL ETHAN (LMFT, LPC)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:ETHAN
Last Name:SELDESS
Suffix:
Gender:M
Credentials:LMFT, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 N. RAVENSWOOD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640
Mailing Address - Country:US
Mailing Address - Phone:336-776-8312
Mailing Address - Fax:
Practice Address - Street 1:5100 N. RAVENSWOOD
Practice Address - Street 2:SUITE 207
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640
Practice Address - Country:US
Practice Address - Phone:336-776-8312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7040101YP2500X
IL178.004640101YP2500X
IL166.000965106H00000X
IL166000965106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103959Medicaid