Provider Demographics
NPI:1033512009
Name:BREWER, GAYNELL
Entity type:Individual
Prefix:DR
First Name:GAYNELL
Middle Name:
Last Name:BREWER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 N MONITOR AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-2568
Mailing Address - Country:US
Mailing Address - Phone:312-719-5499
Mailing Address - Fax:
Practice Address - Street 1:1009 N MONITOR AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-2568
Practice Address - Country:US
Practice Address - Phone:312-719-5499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1851219252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency