Provider Demographics
NPI:1184731341
Name:VONDRAK, ROBERTA SHIRLEY GRUNTORAD (LCPC CADC)
Entity type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:SHIRLEY GRUNTORAD
Last Name:VONDRAK
Suffix:
Gender:F
Credentials:LCPC CADC
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:SHIRLEY
Other - Last Name:VONDRAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13300 S RTE 59
Mailing Address - Street 2:STE B4
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585
Mailing Address - Country:US
Mailing Address - Phone:815-577-8970
Mailing Address - Fax:815-577-8988
Practice Address - Street 1:13300 S RTE 59
Practice Address - Street 2:STE B4
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585
Practice Address - Country:US
Practice Address - Phone:815-577-8970
Practice Address - Fax:815-577-8988
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL20287101YA0400X
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09932324OtherBCBS