Healthcare Provider Details

I. General information

NPI: 1053813592
Provider Name (Legal Business Name): GRETCHEN SELZER ZAGZEBSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GRETCHEN LYNN SELZER

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 05/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 DUNDEE RD STE 101
NORTHBROOK IL
60062-2462
US

IV. Provider business mailing address

3100 DUNDEE RD STE 101
NORTHBROOK IL
60062-2462
US

V. Phone/Fax

Practice location:
  • Phone: 847-313-9490
  • Fax:
Mailing address:
  • Phone: 847-313-9490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.012166
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: