Provider Demographics
NPI:1023155744
Name:PASSALACQUA, GLORIA E (MA LCPC)
Entity type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:E
Last Name:PASSALACQUA
Suffix:
Gender:F
Credentials:MA LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 KOERPER CT
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091
Mailing Address - Country:US
Mailing Address - Phone:847-853-0069
Mailing Address - Fax:847-853-0069
Practice Address - Street 1:6551 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302
Practice Address - Country:US
Practice Address - Phone:847-687-4848
Practice Address - Fax:847-853-0069
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-002124101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional