Provider Demographics
NPI:1568073104
Name:GREMILLION, BREANNE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BREANNE
Middle Name:
Last Name:GREMILLION
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 S FINLEY RD APT 407
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-4850
Mailing Address - Country:US
Mailing Address - Phone:708-310-0246
Mailing Address - Fax:
Practice Address - Street 1:11800 S 75TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1062
Practice Address - Country:US
Practice Address - Phone:708-671-8440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-16
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071010332103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical