MEDICARE: CAMILLE MAYHALL GEHRENBECK, MS, CRC, LCPC, LTD

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	252Y00000X	Early Intervention Provider Agency	060011681	IL

General Provider Information

NPI Number	:	1720432552
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMILLE MAYHALL GEHRENBECK, MS, CRC, LCPC, LTD

Provider Business Mailing Address
First Line	:	4852 N HOYNE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-1408
Country	:	US
Telephone Number	:	773-450-3162
Fax Number	:	312-284-8865

Provider Business Practice Location Address
First Line	:	4852 N HOYNE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-1408
Country	:	US
Telephone Number	:	773-450-3162
Fax Number	:	312-284-8865

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CAMILLE MAYHALL GEHRENBECK
Credential	:
Telephone Number	:	773-450-3162

Provider Enumeration Date	:	04/18/2016
Last Update Date	:	04/18/2016

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