Healthcare Provider Details

I. General information

NPI: 1558731869
Provider Name (Legal Business Name): TYLER GEDVILAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2015
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3933 75TH ST STE 102
AURORA IL
60504-8015
US

IV. Provider business mailing address

28W671 GARYS MILL RD
WINFIELD IL
60190-1564
US

V. Phone/Fax

Practice location:
  • Phone: 630-293-9860
  • Fax: 630-293-9861
Mailing address:
  • Phone: 630-293-9860
  • Fax: 630-293-9861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180012829
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: