Healthcare Provider Details

I. General information

NPI: 1932853991
Provider Name (Legal Business Name): CHETNA VITHAL GORDHAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

1003 MARTIN LUTHER KING DR
BLOOMINGTON IL
61701-1429
US

IV. Provider business mailing address

448 WYLIE DR
NORMAL IL
61761-5405
US

V. Phone/Fax

Practice location:
  • Phone: 888-924-3786
  • Fax:
Mailing address:
  • Phone: 618-512-1502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.024228
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: