Healthcare Provider Details

I. General information

NPI: 1356255210
Provider Name (Legal Business Name): SETH GERSBACH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2545 W DIVERSEY AVE STE 214
CHICAGO IL
60647-7408
US

IV. Provider business mailing address

1646 W FARWELL AVE APT 1A
CHICAGO IL
60626-3619
US

V. Phone/Fax

Practice location:
  • Phone: 585-797-4513
  • Fax:
Mailing address:
  • Phone: 585-797-4513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number150119006
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: