Healthcare Provider Details

I. General information

NPI: 1417100991
Provider Name (Legal Business Name): BLAINE, GERSHENZON, AND HEINS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2008
Last Update Date: 10/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3411 VANTAGE LN
GLENVIEW IL
60026-1366
US

IV. Provider business mailing address

3411 VANTAGE LN
GLENVIEW IL
60026-1366
US

V. Phone/Fax

Practice location:
  • Phone: 847-480-9671
  • Fax: 312-372-0607
Mailing address:
  • Phone: 847-480-9671
  • Fax: 312-372-0607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.003586
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW149005279
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW149000197
License Number StateIL

VIII. Authorized Official

Name: BONNIE E GERSHENZON
Title or Position: PSYCHOTHERAPIST
Credential: MSW AND MA
Phone: 847-480-9671