Provider Demographics
NPI:1689089286
Name:GAYLE, ROXANNE (MA)
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:GAYLE
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 1:1420 W LUNT AVE # 3E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-2849
Mailing Address - Country:US
Mailing Address - Phone:810-790-2884
Mailing Address - Fax:
Practice Address - Street 1:4801 W PETERSON AVE
Practice Address - Street 2:#512
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-5713
Practice Address - Country:US
Practice Address - Phone:773-539-7099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst