Provider Demographics
NPI:1265290050
Name:MCGOWAN, KATIE RAE (PSYD)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:RAE
Last Name:MCGOWAN
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 1:5710 N HERMITAGE AVE APT 205
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-3930
Mailing Address - Country:US
Mailing Address - Phone:516-209-8267
Mailing Address - Fax:
Practice Address - Street 1:5100 N RAVENSWOOD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1710
Practice Address - Country:US
Practice Address - Phone:773-417-6342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.011175103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical