Provider Demographics
NPI:1669281978
Name:GREY, PANDORA (LCPC)
Entity type:Individual
Prefix:
First Name:PANDORA
Middle Name:
Last Name:GREY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 DURANGO TRL
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PLAINS
Mailing Address - State:IL
Mailing Address - Zip Code:62677-4060
Mailing Address - Country:US
Mailing Address - Phone:217-836-7511
Mailing Address - Fax:
Practice Address - Street 1:5400 DURANGO TRL
Practice Address - Street 2:
Practice Address - City:PLEASANT PLAINS
Practice Address - State:IL
Practice Address - Zip Code:62677-4060
Practice Address - Country:US
Practice Address - Phone:217-836-7511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-01
Last Update Date:2025-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180015502101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional