Basic Information
| Provider Information | |||||||||
| NPI: | 1467812677 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHERGOLD | ||||||||
| FirstName: | GREGORY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4152 N KEYSTONE AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606412436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732839071 | ||||||||
| FaxNumber: | 7732839185 | ||||||||
| Practice Location | |||||||||
| Address1: | 4152 N KEYSTONE AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606412436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732839071 | ||||||||
| FaxNumber: | 7732839185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2016 | ||||||||
| LastUpdateDate: | 03/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 178.010098 | IL | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.