Healthcare Provider Details

I. General information

NPI: 1609378462
Provider Name (Legal Business Name): MEGAN GRAY-GORDON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2018
Last Update Date: 03/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 W LAWRENCE AVE FL 2
CHICAGO IL
60640-5017
US

IV. Provider business mailing address

2439 N ALBANY AVE APT 1S
CHICAGO IL
60647-2601
US

V. Phone/Fax

Practice location:
  • Phone: 773-275-2586
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.012522
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: