| NPI |
1932824547 |
The first name of the provider, if the provider
is an individual. |
| Entity Type Code |
1 |
The middle name of the provider, if the provider
is an individual. |
| Provider Last Name Legal Name |
BECKER |
The name prefix or salutation of the provider
if the provider is an individual; for example, Mr., Mrs., or Corporal. |
| Provider First Name |
GABRIEL |
The first name of the provider, if the provider
is an individual. |
| Provider Middle Name |
AARON |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
| Provider Name Prefix Text |
DR. |
The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot
include a Post Office box. |
| Provider Credential Text |
PSY.D. |
The city name in the location address of the provider being identified. |
| Provider Other Last Name |
BECKER |
The State code in the location of the provider
being identified. |
| Provider Other First Name |
GABE |
Other first name by which the provider being identified is or has been known (if an individual). This may be the same as the ‘‘Provider first name’’ if the provider is or has been known by a different last name only. |
| Provider Other Middle Name |
AARON |
The country code in the location address of the provider being identified. |
| Provider Other Name Prefix Text |
DR. |
The telephone number associated with the location address of the provider being identified. |
| Provider Other Credential Text |
PSY.D. |
The fax number associated with the location
address of the provider being identified. |
| Provider Other Last Name Type Code |
5 |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Provider First Line Business Practice Location Address |
2625 BARLEY CT |
The date that a record was last updated or changed. |
| Provider Business Practice Location Address City Name |
AURORA |
The code designating the provider’s gender if the provider is a person. |
| Provider Business Practice Location Address State Name |
IL |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Provider Business Practice Location Address Postal Code |
605026336 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
| Provider Business Practice Location Address Country Code If outside U S |
US |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
| Provider Business Practice Location Address Telephone Number |
6363469427 |
|
| Provider Enumeration Date |
10/5/2022 |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
| Last Update Date |
10/5/2022 |
The date that a record was last updated or changed. |
| Provider Gender Code |
M |
The code designating the provider’s gender if the provider is a person. |
| Healthcare Provider Taxonomy Code 1 |
103TC0700X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Provider License Number 1 |
071.010840 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
| Provider License Number State Code 1 |
IL |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
| Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
| Is Sole Proprietor |
Y |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
| NPI Certification Date |
10/5/2022 |
|