Provider Demographics
NPI:1679803068
Name:BIRCH-GAYTAN, DEBORAH (MA)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:BIRCH-GAYTAN
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 1:4255 N WHIPPLE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-2515
Mailing Address - Country:US
Mailing Address - Phone:312-636-5003
Mailing Address - Fax:
Practice Address - Street 1:2528 N LINCOLN AVE
Practice Address - Street 2:SUITE 116
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2333
Practice Address - Country:US
Practice Address - Phone:312-636-5003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0138931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical