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General NPI Number Information
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NPI Number | 1669281978
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Entity Type | Individual
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Provider Name | PANDORA GREY LCPC
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Gender | Female
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Dates
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Enumeration Date | 01/01/2025
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Last Update Date | 01/01/2025
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Provider Practice Location Address
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Address Line | 5400 DURANGO TRL
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City | PLEASANT PLAINS
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State | IL
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Zip | 62677-4060
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Country | US
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Telephone | 217-836-7511
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Fax |
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Provider Business Mailing Address
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Address Line | 5400 DURANGO TRL
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City | PLEASANT PLAINS
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State | IL
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Zip | 62677-4060
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Country | US
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Telephone | 217-836-7511
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180015502
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License Number State | IL
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