Provider Demographics
NPI:1972543668
Name:WAKEFIELD, GARY PAUL (MSW LCSW BCD)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:PAUL
Last Name:WAKEFIELD
Suffix:
Gender:M
Credentials:MSW LCSW BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1497 NORTH LAFOX
Mailing Address - Street 2:
Mailing Address - City:SOUTH ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60177-1227
Mailing Address - Country:US
Mailing Address - Phone:847-697-4747
Mailing Address - Fax:847-697-4717
Practice Address - Street 1:1497 NORTH LAFOX
Practice Address - Street 2:
Practice Address - City:SOUTH ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60177-1227
Practice Address - Country:US
Practice Address - Phone:847-697-4747
Practice Address - Fax:847-697-4717
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
04572027OtherBLUE CROSS BLUE SHIELD