Provider Demographics
NPI:1912718644
Name:THEODOSIADIS, GIA (EDS)
Entity type:Individual
Prefix:
First Name:GIA
Middle Name:
Last Name:THEODOSIADIS
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1847 S ALLPORT ST APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-5789
Mailing Address - Country:US
Mailing Address - Phone:847-226-8874
Mailing Address - Fax:
Practice Address - Street 1:1847 S ALLPORT ST APT 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-5789
Practice Address - Country:US
Practice Address - Phone:847-226-8874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2291786103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool