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General NPI Number Information
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NPI Number | 1205154762
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Entity Type | Organization
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Legal Business Name | GATHER SPARKS CORPORATION
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Dates
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Enumeration Date | 05/08/2010
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Last Update Date | 12/03/2010
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Provider Practice Location Address
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Address Line | 180 N MICHIGAN AVE SUITE 1910C
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City | CHICAGO
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State | IL
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Zip | 60601-7401
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Country | US
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Telephone | 312-859-6512
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Fax |
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Provider Business Mailing Address
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Address Line | 600 S DEARBORN ST APT 1211
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City | CHICAGO
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State | IL
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Zip | 60605-1895
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Country | US
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Telephone | 312-859-6512
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Fax |
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | MICHAEL DAVID COLOMBATTO
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Credential | PSY.D.
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Telephone | 312-859-6512
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071005566
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License Number State | IL
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