Basic Information
| Provider Information | |||||||||
| NPI: | 1407273709 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRESK | ||||||||
| FirstName: | SARAH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3805 E MAIN ST | ||||||||
| Address2: | STE M | ||||||||
| City: | ST CHARLES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601742487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306465200 | ||||||||
| FaxNumber: | 6306465202 | ||||||||
| Practice Location | |||||||||
| Address1: | 3805 E MAIN ST | ||||||||
| Address2: | STE M | ||||||||
| City: | ST CHARLES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601742487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306465200 | ||||||||
| FaxNumber: | 6306465202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2014 | ||||||||
| LastUpdateDate: | 03/25/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 209011363 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.