Healthcare Provider Details

I. General information

NPI: 1306387220
Provider Name (Legal Business Name): GRISEL GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2017
Last Update Date: 12/08/2025
Certification Date:
Deactivation Date: 02/28/2018
Reactivation Date: 12/08/2025

III. Provider practice location address

2849 N KOSTNER AVE
CHICAGO IL
60641-5346
US

IV. Provider business mailing address

2849 N KOSTNER AVE
CHICAGO IL
60641-5346
US

V. Phone/Fax

Practice location:
  • Phone: 773-931-7625
  • Fax:
Mailing address:
  • Phone: 773-931-7625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: