MEDICARE: MRS. GWEN GASSMAN FRALEY M.S., C.G.C.

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	170300000X	Genetic Counselor (M.S.)

General Provider Information

NPI Number	:	1952386427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GWEN GASSMAN FRALEY M.S., C.G.C.

Provider Business Mailing Address
First Line	:	1248 W THORNDALE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-3348
Country	:	US
Telephone Number	:	773-807-1614
Fax Number	:	847-733-5394

Provider Business Practice Location Address
First Line	:	2650 RIDGE AVE
Second Line	:	FETAL DIAGNOSTICS
City	:	EVANSTON
State	:	IL
Zip	:	60201-1718
Country	:	US
Telephone Number	:	847-570-2864
Fax Number	:	847-733-5394

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

Provider Enumeration Date	:	12/07/2005
Last Update Date	:	07/08/2007

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