Provider Demographics
NPI:1114708765
Name:GREGORASH, ALEXIS MERCEDES
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:MERCEDES
Last Name:GREGORASH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 STATE ST APT 2R
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-3981
Mailing Address - Country:US
Mailing Address - Phone:815-582-6252
Mailing Address - Fax:
Practice Address - Street 1:14933 FOUNDERS XING
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-6712
Practice Address - Country:US
Practice Address - Phone:708-737-7968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.019279101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional