Provider Demographics
NPI:1457814360
Name:PETERSEN, GRAZYNA GABRIELA (LCSW, CADC)
Entity Type:Individual
Prefix:
First Name:GRAZYNA
Middle Name:GABRIELA
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LCSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 COMMERCE CT STE 300-3
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-3709
Mailing Address - Country:US
Mailing Address - Phone:773-739-0992
Mailing Address - Fax:773-733-4119
Practice Address - Street 1:4300 COMMERCE CT STE 300-3
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-3709
Practice Address - Country:US
Practice Address - Phone:773-739-0992
Practice Address - Fax:773-733-4119
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL33287101YA0400X
IL149.0210921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty