Provider Demographics
NPI:1275228280
Name:WALL, CHACE THOMAS GABRIELSON
Entity type:Individual
Prefix:
First Name:CHACE
Middle Name:THOMAS GABRIELSON
Last Name:WALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 S ALBANY AVE # 2F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-3483
Mailing Address - Country:US
Mailing Address - Phone:773-988-1269
Mailing Address - Fax:
Practice Address - Street 1:8 S MICHIGAN AVE FL 7
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603-3357
Practice Address - Country:US
Practice Address - Phone:312-897-1420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-06
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.020258101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor