Provider Demographics
NPI:1013397678
Name:GRANT, GWEN IRENE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GWEN
Middle Name:IRENE
Last Name:GRANT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:IRENE
Other - Last Name:WILLIAMSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:17120 W 145TH ST
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-2297
Mailing Address - Country:US
Mailing Address - Phone:773-620-6512
Mailing Address - Fax:
Practice Address - Street 1:14953 S VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-5804
Practice Address - Country:US
Practice Address - Phone:773-620-6512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-08
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007699103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical