Provider Demographics
NPI:1770235814
Name:GOPAL, TAMARA (LSW)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:GOPAL
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5715 HAMPTON DR
Mailing Address - Street 2:
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047-5050
Mailing Address - Country:US
Mailing Address - Phone:814-282-3933
Mailing Address - Fax:
Practice Address - Street 1:200 N FAIRWAY DR STE 208
Practice Address - Street 2:
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1803
Practice Address - Country:US
Practice Address - Phone:847-996-6666
Practice Address - Fax:847-996-6665
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150105520104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker