Basic Information
Provider Information
NPI: 1033559273
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JOHNSON
FirstName: GABRIELLE
MiddleName: ANNE
NamePrefix:  
NameSuffix:  
Credential: LPC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1 HAYWARD CT
Address2:  
City: LAKE IN THE HILLS
State: IL
PostalCode: 601566327
CountryCode: US
TelephoneNumber: 8477786992
FaxNumber:  
Practice Location
Address1: 530 ROCKLAND RD FL 1
Address2: SUITE 100
City: CRYSTAL LAKE
State: IL
PostalCode: 600144131
CountryCode: US
TelephoneNumber: 8477786992
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/02/2013
LastUpdateDate: 01/22/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YM0800X178.007894ILN Behavioral Health & Social Service ProvidersCounselorMental Health
101YP2500X180.008951ILY Behavioral Health & Social Service ProvidersCounselorProfessional

No ID Information.


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