=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669017299
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AGATHE ANN GABRIEL LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2019
-----------------------------------------------------
Last Update Date | 11/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 CENTRAL AVE STE 202
-----------------------------------------------------
City | NORTHFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60093-3024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-579-9496
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30007 N WAUKEGAN RD APT 117
-----------------------------------------------------
City | LAKE BLUFF
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60044-1033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-904-9498
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149.021401
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------