Provider Demographics
NPI:1740298645
Name:GOREN, SALLY GERALDINE (MA LCSW)
Entity type:Individual
Prefix:MS
First Name:SALLY
Middle Name:GERALDINE
Last Name:GOREN
Suffix:
Gender:F
Credentials:MA LCSW
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:GERALDINE
Other - Last Name:FOX
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:215 PIN OAK DR
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-3128
Mailing Address - Country:US
Mailing Address - Phone:847-251-3221
Mailing Address - Fax:847-251-3491
Practice Address - Street 1:215 PIN OAK DR
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-3128
Practice Address - Country:US
Practice Address - Phone:847-251-3221
Practice Address - Fax:847-251-3491
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
579660Medicare ID - Type Unspecified