Provider Demographics
NPI:1265909600
Name:GILLENWATER, STEPHEN (LCSW)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:
Last Name:GILLENWATER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1036 N AUSTIN BLVD
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1714
Mailing Address - Country:US
Mailing Address - Phone:708-466-4870
Mailing Address - Fax:
Practice Address - Street 1:1645 W JACKSON BLVD STE 315A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3227
Practice Address - Country:US
Practice Address - Phone:312-942-2777
Practice Address - Fax:312-942-2822
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490203561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149020356OtherLCSW LICENSE NUMBER