Provider Demographics
NPI:1851625677
Name:GOTTFRIED, JOSEPH SHAINE (MA, LCPC)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:SHAINE
Last Name:GOTTFRIED
Suffix:
Gender:M
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:BRENT
Other - Middle Name:FREDRICH
Other - Last Name:BREDTHAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPC
Mailing Address - Street 1:5049 N CENTRAL PARK AVE APT 3C
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-5537
Mailing Address - Country:US
Mailing Address - Phone:773-633-8057
Mailing Address - Fax:
Practice Address - Street 1:3850 N LAWNDALE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-4115
Practice Address - Country:US
Practice Address - Phone:773-633-8057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-25
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009130101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional