Provider Demographics
NPI:1063240471
Name:GRABERT, REN (LSW)
Entity type:Individual
Prefix:
First Name:REN
Middle Name:
Last Name:GRABERT
Suffix:
Gender:U
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 W MONTROSE AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-1562
Mailing Address - Country:US
Mailing Address - Phone:312-377-5261
Mailing Address - Fax:
Practice Address - Street 1:2650 W MONTROSE AVE STE 102
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-1562
Practice Address - Country:US
Practice Address - Phone:312-377-5261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-25
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150113667104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker