Provider Demographics
NPI:1417781576
Name:MALVESTUTO, GAIL (EDD)
Entity type:Individual
Prefix:MISS
First Name:GAIL
Middle Name:
Last Name:MALVESTUTO
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-2424
Mailing Address - Country:US
Mailing Address - Phone:708-308-9941
Mailing Address - Fax:
Practice Address - Street 1:555 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WAUCONDA
Practice Address - State:IL
Practice Address - Zip Code:60084-1229
Practice Address - Country:US
Practice Address - Phone:847-526-7690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-29
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14295951041S0200X
IL2291042103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool