=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609499318
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL ANDREW GUTOWSKI
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2020
-----------------------------------------------------
Last Update Date | 05/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 939 GALENA SQUARE DR
-----------------------------------------------------
City | GALENA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61036-1355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-777-1300
-----------------------------------------------------
Fax | 815-777-1308
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2138 CUMBERLAND ST
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61103-4146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-978-0979
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 13846
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------