Provider Demographics
NPI:1376816132
Name:CALVIRD, GREGG
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:
Last Name:CALVIRD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CAL
Other - Middle Name:
Other - Last Name:CALVIRD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1256 W BRYN MAWR AVE
Mailing Address - Street 2:2N
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-4285
Mailing Address - Country:US
Mailing Address - Phone:773-405-1819
Mailing Address - Fax:
Practice Address - Street 1:1300 W BELMONT AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657
Practice Address - Country:US
Practice Address - Phone:773-880-1310
Practice Address - Fax:773-880-1321
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.007295101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional