Healthcare Provider Details

I. General information

NPI: 1255203592
Provider Name (Legal Business Name): GRAY OWL PSYCHOTHERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2025
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4825 SCOTT ST STE 208
SCHILLER PARK IL
60176-1210
US

IV. Provider business mailing address

360 TRATEBAS RD
VALPARAISO IN
46383-9752
US

V. Phone/Fax

Practice location:
  • Phone: 773-470-9999
  • Fax:
Mailing address:
  • Phone: 773-470-9999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: GREG DZIEDZIC
Title or Position: OWNER
Credential: LCPC
Phone: 224-595-2735