Healthcare Provider Details

I. General information

NPI: 1174297204
Provider Name (Legal Business Name): ALICIA GATTIS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALICIA MORENO

II. Dates (important events)

Enumeration Date: 08/03/2021
Last Update Date: 08/03/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1767 W WILSON AVE
CHICAGO IL
60640-4516
US

IV. Provider business mailing address

2924 N KOLMAR AVE
CHICAGO IL
60641-5205
US

V. Phone/Fax

Practice location:
  • Phone: 847-651-8643
  • Fax:
Mailing address:
  • Phone: 309-235-1378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178015640
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: