Healthcare Provider Details

I. General information

NPI: 1427898238
Provider Name (Legal Business Name): MICHAEL GRZEJKA LCP
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2024
Last Update Date: 07/03/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W STATE ST
GENEVA IL
60134-2106
US

IV. Provider business mailing address

229 WHITE OAK ST
HAMPSHIRE IL
60140-4003
US

V. Phone/Fax

Practice location:
  • Phone: 630-300-8928
  • Fax:
Mailing address:
  • Phone: 847-226-0416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178020119
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: