Provider Demographics
NPI:1215692314
Name:CHATHAM, GARY LEE (MA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:LEE
Last Name:CHATHAM
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8801 N UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-1635
Mailing Address - Country:US
Mailing Address - Phone:309-676-0538
Mailing Address - Fax:
Practice Address - Street 1:8801 N UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1635
Practice Address - Country:US
Practice Address - Phone:309-676-0538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor