Healthcare Provider Details

I. General information

NPI: 1831925320
Provider Name (Legal Business Name): GABRIELLA BONUCCI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 09/11/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 W IRVING PARK RD STE 302
CHICAGO IL
60613-2462
US

IV. Provider business mailing address

933 W CORNELIA AVE APT 1A
CHICAGO IL
60657-1762
US

V. Phone/Fax

Practice location:
  • Phone: 312-248-2882
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.020519
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: