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General NPI Number Information
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NPI Number | 1417100991
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Entity Type | Organization
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Legal Business Name | BLAINE, GERSHENZON, AND HEINS
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Dates
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Enumeration Date | 10/29/2008
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Last Update Date | 10/29/2008
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Provider Practice Location Address
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Address Line | 3411 VANTAGE LN
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City | GLENVIEW
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State | IL
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Zip | 60026-1366
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Country | US
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Telephone | 847-480-9671
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Fax | 312-372-0607
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Provider Business Mailing Address
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Address Line | 3411 VANTAGE LN
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City | GLENVIEW
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State | IL
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Zip | 60026-1366
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Country | US
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Telephone | 847-480-9671
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Fax | 312-372-0607
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Authorized Official
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Title or Position | PSYCHOTHERAPIST
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Name | BONNIE E GERSHENZON
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Credential | MSW AND MA
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Telephone | 847-480-9671
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW149005279
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW149000197
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071.003586
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License Number State | IL
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