Provider Demographics
NPI:1922736073
Name:GRONCESKI, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:GRONCESKI
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 1:3001 N SOUTHPORT AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-4289
Mailing Address - Country:US
Mailing Address - Phone:773-799-8966
Mailing Address - Fax:
Practice Address - Street 1:3001 N SOUTHPORT AVE FL 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-4289
Practice Address - Country:US
Practice Address - Phone:312-508-3645
Practice Address - Fax:312-971-8554
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL178019506101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program