1366595407 NPI number — MR. GERALD JOSEPH GRIPSHOVER LCSW

Table of content: MR. GERALD JOSEPH GRIPSHOVER LCSW (NPI 1366595407)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366595407 NPI number — MR. GERALD JOSEPH GRIPSHOVER LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRIPSHOVER
Provider First Name:
GERALD
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366595407
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4020 206TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MATTESON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60443-1722
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-748-4214
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3612 LINCOLN HWY
Provider Second Line Business Practice Location Address:
SUITE 14B
Provider Business Practice Location Address City Name:
OLYMPIA FIELDS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60461-1627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-288-4089
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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