Provider Demographics
NPI:1770353757
Name:GERUC, RACHEL JANE
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:JANE
Last Name:GERUC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 W POLK ST APT 105
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-1770
Mailing Address - Country:US
Mailing Address - Phone:859-248-9005
Mailing Address - Fax:
Practice Address - Street 1:1657 W CORTLAND ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1119
Practice Address - Country:US
Practice Address - Phone:877-486-4140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician