Provider Demographics
NPI:1154730117
Name:GAWENDA, CAROLYN
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:GAWENDA
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 1:45W140 TIMBERVIEW LN
Mailing Address - Street 2:
Mailing Address - City:HAMPSHIRE
Mailing Address - State:IL
Mailing Address - Zip Code:60140-6806
Mailing Address - Country:US
Mailing Address - Phone:847-533-2471
Mailing Address - Fax:
Practice Address - Street 1:45W140 TIMBERVIEW LN
Practice Address - Street 2:
Practice Address - City:HAMPSHIRE
Practice Address - State:IL
Practice Address - Zip Code:60140-6806
Practice Address - Country:US
Practice Address - Phone:847-533-2471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.005827225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist