Provider Demographics
NPI:1174105209
Name:GAWNE, ALISSA MARIE
Entity type:Individual
Prefix:
First Name:ALISSA
Middle Name:MARIE
Last Name:GAWNE
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 1:22 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:YORKVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60560-9808
Mailing Address - Country:US
Mailing Address - Phone:630-926-2026
Mailing Address - Fax:
Practice Address - Street 1:212 S BRIDGE ST
Practice Address - Street 2:
Practice Address - City:YORKVILLE
Practice Address - State:IL
Practice Address - Zip Code:60560-1502
Practice Address - Country:US
Practice Address - Phone:630-926-2026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.105017104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker