MEDICARE: GREGORY GRACE MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	149005245	IL

General Provider Information

NPI Number	:	1083641435
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY GRACE MSW

Provider Business Mailing Address
First Line	:	3001 N. GREENBAY ROAD
Second Line	:
City	:	NORTH CHICAGO
State	:	IL
Zip	:	60064-0000
Country	:	US
Telephone Number	:	224-610-3326
Fax Number	:

Provider Business Practice Location Address
First Line	:	3001 N. GREENBAY RD
Second Line	:
City	:	NORTH CHICAGO
State	:	IL
Zip	:	60064-2318
Country	:	US
Telephone Number	:	847-688-1900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	08/12/2010

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