Healthcare Provider Details

I. General information

NPI: 1235015553
Provider Name (Legal Business Name): GHADA ABDALLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2025
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 E UNIVERSITY AVE
CHAMPAIGN IL
61820-3828
US

IV. Provider business mailing address

505 E UNIVERSITY AVE
CHAMPAIGN IL
61820-3828
US

V. Phone/Fax

Practice location:
  • Phone: 860-208-9297
  • Fax:
Mailing address:
  • Phone: 860-208-9297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number150114066
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: