Provider Demographics
NPI:1477260883
Name:GRANDBERRY, BRE'SHAE (LCSW)
Entity Type:Individual
Prefix:
First Name:BRE'SHAE
Middle Name:
Last Name:GRANDBERRY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12138 S THROOP ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-5422
Mailing Address - Country:US
Mailing Address - Phone:773-987-2942
Mailing Address - Fax:
Practice Address - Street 1:5801 N. PULASKI
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646
Practice Address - Country:US
Practice Address - Phone:312-744-1906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical