Provider Demographics
NPI:1053846881
Name:CONCODORA, GREGORY CLEMENT (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:CLEMENT
Last Name:CONCODORA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 N RAVENSWOOD AVE
Mailing Address - Street 2:SUITE 238
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1710
Mailing Address - Country:US
Mailing Address - Phone:718-483-4841
Mailing Address - Fax:
Practice Address - Street 1:5100 N RAVENSWOOD AVE
Practice Address - Street 2:SUITE 238
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1710
Practice Address - Country:US
Practice Address - Phone:718-483-4841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-30
Last Update Date:2017-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009527103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent