Provider Demographics
NPI:1194978510
Name:FIELDS, GAYLA RENEA (MS, LCPC)
Entity type:Individual
Prefix:
First Name:GAYLA
Middle Name:RENEA
Last Name:FIELDS
Suffix:
Gender:F
Credentials:MS, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 CAROL ANN DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3435
Mailing Address - Country:US
Mailing Address - Phone:618-402-7735
Mailing Address - Fax:
Practice Address - Street 1:4 INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:FREEBURG
Practice Address - State:IL
Practice Address - Zip Code:62243-3229
Practice Address - Country:US
Practice Address - Phone:618-402-7735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180007036101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health