Healthcare Provider Details

I. General information

NPI: 1316558471
Provider Name (Legal Business Name): ERICA GADDY APRN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2020
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 REVERE DR STE 100
NORTHBROOK IL
60062-1590
US

IV. Provider business mailing address

60 REVERE DR STE 100
NORTHBROOK IL
60062-1590
US

V. Phone/Fax

Practice location:
  • Phone: 224-306-1879
  • Fax:
Mailing address:
  • Phone: 224-306-1879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ERICA GADDY
Title or Position: OWNER
Credential: APRN
Phone: 224-306-1879