Basic Information
| Provider Information | |||||||||
| NPI: | 1568749513 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAUMEN | ||||||||
| FirstName: | GRETCHEN | ||||||||
| MiddleName: | KATHLEEN | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, ATC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 425 FAWELL BLVD | ||||||||
| Address2: | |||||||||
| City: | GLEN ELLYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601376708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309422346 | ||||||||
| FaxNumber: | 6309423780 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 NORTH WINFIELD RD | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303392202 | ||||||||
| FaxNumber: | 7084095179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2011 | ||||||||
| LastUpdateDate: | 12/10/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 096.003065 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.