Healthcare Provider Details

I. General information

NPI: 1487320834
Provider Name (Legal Business Name): ANNE GAMACHE PSYCHOTHERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

564 W RANDOLPH ST STE 200
CHICAGO IL
60661-2218
US

IV. Provider business mailing address

564 W RANDOLPH ST STE 200
CHICAGO IL
60661-2218
US

V. Phone/Fax

Practice location:
  • Phone: 847-461-3168
  • Fax:
Mailing address:
  • Phone: 847-461-3168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANNE GAMACHE
Title or Position: MANAGING OWNER
Credential: LCPC
Phone: 847-461-3168