Provider Demographics
NPI:1497270318
Name:GRIGG, ANDREA RENEE (BCABA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:RENEE
Last Name:GRIGG
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:932 N HONORE ST APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-4988
Mailing Address - Country:US
Mailing Address - Phone:248-761-0771
Mailing Address - Fax:
Practice Address - Street 1:1739 N ELSTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-1544
Practice Address - Country:US
Practice Address - Phone:248-761-0771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-11
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 156F00000X
IL0-21-12660106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No156F00000XEye and Vision Services ProvidersTechnician/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0-21-12660OtherBCABA