Provider Demographics
NPI:1366595407
Name:GRIPSHOVER, GERALD JOSEPH (LCSW)
Entity type:Individual
Prefix:MR
First Name:GERALD
Middle Name:JOSEPH
Last Name:GRIPSHOVER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4020 206TH ST
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-1722
Mailing Address - Country:US
Mailing Address - Phone:708-748-4214
Mailing Address - Fax:
Practice Address - Street 1:3612 LINCOLN HWY
Practice Address - Street 2:SUITE 14B
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1627
Practice Address - Country:US
Practice Address - Phone:708-288-4089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209339Medicare ID - Type Unspecified