Provider Demographics
NPI:1194267385
Name:COUNSELING CENTER OF GRAYSLAKE LTD.
Entity type:Organization
Organization Name:COUNSELING CENTER OF GRAYSLAKE LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTINATO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:847-962-9549
Mailing Address - Street 1:1190 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-7960
Mailing Address - Country:US
Mailing Address - Phone:847-962-9549
Mailing Address - Fax:847-549-2235
Practice Address - Street 1:142 HAWLEY ST STE 5
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-3653
Practice Address - Country:US
Practice Address - Phone:847-962-9549
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-06
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF300232686OtherMEDICARE PTAN
IL149.014706OtherLICENSE - SOCIAL WORKER, CLINICAL