Healthcare Provider Details

I. General information

NPI: 1568968865
Provider Name (Legal Business Name): RAYELL MARIE GRAYSON LCPC, CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 N RAVENSWOOD AVE STE 250
CHICAGO IL
60640-5802
US

IV. Provider business mailing address

4411 N RAVENSWOOD AVE STE 250
CHICAGO IL
60640-5802
US

V. Phone/Fax

Practice location:
  • Phone: 773-888-3240
  • Fax:
Mailing address:
  • Phone: 773-892-1933
  • Fax: 773-869-5358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number178.013373
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.012206
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: