Provider Demographics
NPI:1124146857
Name:WALDMAN, GWENN (LCPC)
Entity type:Individual
Prefix:MS
First Name:GWENN
Middle Name:
Last Name:WALDMAN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 RIDGE AVE
Mailing Address - Street 2:UNIT 211
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3621
Mailing Address - Country:US
Mailing Address - Phone:847-507-5151
Mailing Address - Fax:
Practice Address - Street 1:618 LIBRARY PL
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-2908
Practice Address - Country:US
Practice Address - Phone:847-733-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01636492OtherLCPC