Provider Demographics
NPI:1730165317
Name:DAVIDSON, GRETCHEN GENZ (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:GENZ
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 MAIN ST
Mailing Address - Street 2:SUITE 2-E
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1701
Mailing Address - Country:US
Mailing Address - Phone:847-869-8856
Mailing Address - Fax:847-329-9263
Practice Address - Street 1:717 MAIN ST
Practice Address - Street 2:SUITE 2-E
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-1701
Practice Address - Country:US
Practice Address - Phone:847-869-8856
Practice Address - Fax:847-329-9263
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL336220Medicare ID - Type Unspecified