Provider Demographics
NPI:1699784850
Name:GAYNOR, JUDITH LYNNE (MA)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:LYNNE
Last Name:GAYNOR
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2436 ORRINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-2433
Mailing Address - Country:US
Mailing Address - Phone:847-328-3660
Mailing Address - Fax:
Practice Address - Street 1:2436 ORRINGTON AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-2433
Practice Address - Country:US
Practice Address - Phone:847-328-3660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01632660OtherBLUECROSS BLUESHIELD