Healthcare Provider Details

I. General information

NPI: 1336079318
Provider Name (Legal Business Name): CHANTEL GRAY LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10540 S WESTERN AVE
CHICAGO IL
60643-2536
US

IV. Provider business mailing address

7950 S PAXTON AVE
CHICAGO IL
60617-1595
US

V. Phone/Fax

Practice location:
  • Phone: 872-400-6113
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150129176
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: