=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720432552
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAMILLE MAYHALL GEHRENBECK, MS, CRC, LCPC, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2016
-----------------------------------------------------
Last Update Date | 04/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4852 N HOYNE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60625-1408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-450-3162
-----------------------------------------------------
Fax | 312-284-8865
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4852 N HOYNE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60625-1408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-450-3162
-----------------------------------------------------
Fax | 312-284-8865
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CAMILLE MAYHALL GEHRENBECK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-450-3162
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 060011681
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------