Provider Demographics
NPI:1982156550
Name:GEREDINE, TOLAYA (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:TOLAYA
Middle Name:
Last Name:GEREDINE
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 1:4137 S PRAIRIE AVE # 2S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-2633
Mailing Address - Country:US
Mailing Address - Phone:312-898-5007
Mailing Address - Fax:
Practice Address - Street 1:1136 S DELANO CT W STE B201
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605
Practice Address - Country:US
Practice Address - Phone:128-985-0073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-31
Last Update Date:2019-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180012190101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional