=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023155744
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GLORIA E PASSALACQUA MA LCPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2007
-----------------------------------------------------
Last Update Date | 08/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6551 W NORTH AVE
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-687-4848
-----------------------------------------------------
Fax | 847-853-0069
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 KOERPER CT
-----------------------------------------------------
City | WILMETTE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-853-0069
-----------------------------------------------------
Fax | 847-853-0069
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180-002124
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------