Healthcare Provider Details

I. General information

NPI: 1205492097
Provider Name (Legal Business Name): GRACE ANTIONETTE HOBSON MACC, LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15309 DORCHESTER AVE
DOLTON IL
60419-3127
US

IV. Provider business mailing address

15309 DORCHESTER AVE
DOLTON IL
60419-3127
US

V. Phone/Fax

Practice location:
  • Phone: 708-769-2683
  • Fax:
Mailing address:
  • Phone: 708-769-2683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180013035
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: