Provider Demographics
NPI:1023669504
Name:GALLARDO, STEPHANIE (LSW)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:GALLARDO
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 1:4024 N MASON AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-1611
Mailing Address - Country:US
Mailing Address - Phone:773-206-3102
Mailing Address - Fax:
Practice Address - Street 1:1640 W ROOSEVELT RD # 104
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1316
Practice Address - Country:US
Practice Address - Phone:312-413-1871
Practice Address - Fax:312-413-1593
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.103884104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker