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General NPI Number Information
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NPI Number | 1295465839
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Entity Type | Individual
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Provider Name | LESLIE E GRANGE LPC
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Gender | Male
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Dates
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Enumeration Date | 06/15/2022
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Last Update Date | 06/15/2022
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Provider Practice Location Address
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Address Line | 3317 W 95TH ST
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City | EVERGREEN PARK
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State | IL
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Zip | 60805-2243
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Country | US
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Telephone | 708-381-1176
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Fax |
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Provider Business Mailing Address
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Address Line | 3317 W 95TH ST
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City | EVERGREEN PARK
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State | IL
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Zip | 60805-2243
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Country | US
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Telephone | 708-381-1176
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 178.018066
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License Number State | IL
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