Provider Demographics
NPI:1386770238
Name:GREVENGOED, RICHARD (LCPC)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:GREVENGOED
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:DR
Other - First Name:RICHARD
Other - Middle Name:
Other - Last Name:GREVENGOED
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC
Mailing Address - Street 1:559. E.161ST PLACE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473
Mailing Address - Country:US
Mailing Address - Phone:708-474-6211
Mailing Address - Fax:
Practice Address - Street 1:559 E 161ST PL
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-1618
Practice Address - Country:US
Practice Address - Phone:708-474-6211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1803926101YP2500X
IN1803926101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional