=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760717524
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA ANN GREGORY M.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2009
-----------------------------------------------------
Last Update Date | 11/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 W ADAMS ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60606-5101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-365-2221
-----------------------------------------------------
Fax | 573-745-1196
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 W ADAMS ST STE 514
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60606-5108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-365-2221
-----------------------------------------------------
Fax | 573-745-1196
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 2008036881
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------