Provider Demographics
NPI:1215253307
Name:GRANT, PHYLLIS DARCEL (LCSW)
Entity type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:DARCEL
Last Name:GRANT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 E 75TH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-3607
Mailing Address - Country:US
Mailing Address - Phone:773-643-0500
Mailing Address - Fax:773-643-0545
Practice Address - Street 1:2011 EAST 75TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-2302
Practice Address - Country:US
Practice Address - Phone:773-643-0500
Practice Address - Fax:773-643-0545
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-14
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490139061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149013906OtherILLINOIS LICENSE NUMBER