Provider Demographics
NPI:1124457510
Name:WEINBERG-GORDON, BETH
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:WEINBERG-GORDON
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 1:2011 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-2414
Mailing Address - Country:US
Mailing Address - Phone:309-687-7972
Mailing Address - Fax:309-687-7999
Practice Address - Street 1:2011 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-2414
Practice Address - Country:US
Practice Address - Phone:309-687-7972
Practice Address - Fax:309-687-7999
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0045341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical