Healthcare Provider Details

I. General information

NPI: 1396592267
Provider Name (Legal Business Name): CONNOR GWALTNEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2024
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E 1ST ST STE 2W
HINSDALE IL
60521-4258
US

IV. Provider business mailing address

464 W VERRET ST
ELMHURST IL
60126-4937
US

V. Phone/Fax

Practice location:
  • Phone: 773-242-8898
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: