MEDICARE: GRETCHEN A BOULES PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	071005051	IL
2	103TC0700X	Clinical Psychologist	071005051	IL
3	103TP0016X	Prescribing (Medical) Psychologist	074.000005	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0001621856	OTHER	IL	BC BS OF IL

General Provider Information

NPI Number	:	1710082474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRETCHEN A BOULES PSYD

Provider Business Mailing Address
First Line	:	200 S FRONTAGE RD STE 324
Second Line	:
City	:	BURR RIDGE
State	:	IL
Zip	:	60527-6953
Country	:	US
Telephone Number	:	630-321-9809
Fax Number	:

Provider Business Practice Location Address
First Line	:	33 S GARFIELD AVE
Second Line	:
City	:	HINSDALE
State	:	IL
Zip	:	60521
Country	:	US
Telephone Number	:	630-321-9809
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	06/16/2026

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