1427526193 NPI number — MRS. MACAYLA MARIE GERDOVICH LPC

Table of content: MRS. MACAYLA MARIE GERDOVICH LPC (NPI 1427526193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427526193 NPI number — MRS. MACAYLA MARIE GERDOVICH LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GERDOVICH
Provider First Name:
MACAYLA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAYNARD
Provider Other First Name:
MACAYLA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1427526193
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
825 N 2401ST RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OGLESBY
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61348-9750
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-343-8344
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
643 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OTTAWA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61350-2717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-541-5299
Provider Business Practice Location Address Fax Number:
815-214-2101
Provider Enumeration Date:
11/11/2018

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: 101YS0200X , with the licence number:  2368884 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 178.013904 , 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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