Provider Demographics
NPI:1710082474
Name:BOULES, GRETCHEN A (PSYD)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:A
Last Name:BOULES
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S FRONTAGE RD STE 324
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-6953
Mailing Address - Country:US
Mailing Address - Phone:630-321-9809
Mailing Address - Fax:
Practice Address - Street 1:33 S GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521
Practice Address - Country:US
Practice Address - Phone:630-321-9809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL074.000005103TP0016X
IL071005051103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001621856OtherBC BS OF IL
212616Medicare ID - Type Unspecified