Healthcare Provider Details

I. General information

NPI: 1265909600
Provider Name (Legal Business Name): STEPHEN GILLENWATER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 W JACKSON BLVD STE 315A
CHICAGO IL
60612-3227
US

IV. Provider business mailing address

1036 N AUSTIN BLVD
OAK PARK IL
60302-1714
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-2777
  • Fax: 312-942-2822
Mailing address:
  • Phone: 708-466-4870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149020356
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: