Provider Demographics
NPI:1689016289
Name:VARGHESE, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:VARGHESE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11447 2ND ST
Mailing Address - Street 2:SUITE 9B
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-9522
Mailing Address - Country:US
Mailing Address - Phone:815-601-4673
Mailing Address - Fax:
Practice Address - Street 1:501 N RIVERSIDE DR STE 110
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5918
Practice Address - Country:US
Practice Address - Phone:815-601-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178008473101YP2500X
101YP2500X
IL180011272101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional