Provider Demographics
NPI:1437625985
Name:FRAYN, BRENNA ROSE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:ROSE
Last Name:FRAYN
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:862 N HERMITAGE AVE APT 1F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-5402
Mailing Address - Country:US
Mailing Address - Phone:708-560-6980
Mailing Address - Fax:
Practice Address - Street 1:1361 E LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-2153
Practice Address - Country:US
Practice Address - Phone:815-462-4273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.013347101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL178.013347OtherILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION