Provider Demographics
NPI:1346663184
Name:GRAY, SHANYA (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:SHANYA
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9616 S PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1222
Mailing Address - Country:US
Mailing Address - Phone:630-415-4295
Mailing Address - Fax:312-488-4160
Practice Address - Street 1:9616 S PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1222
Practice Address - Country:US
Practice Address - Phone:630-415-4295
Practice Address - Fax:312-488-4160
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007770101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional