Healthcare Provider Details

I. General information

NPI: 1871309559
Provider Name (Legal Business Name): KATHY JEAN GRZELAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2024
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W CARROLL AVE STE 205
CHICAGO IL
60612-2401
US

IV. Provider business mailing address

1901 W CARROLL AVE STE 205
CHICAGO IL
60612-2401
US

V. Phone/Fax

Practice location:
  • Phone: 773-292-4076
  • Fax:
Mailing address:
  • Phone: 773-292-4076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.003927
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: