Provider Demographics
NPI:1891580213
Name:TERRY-GRAVES, LATANDA
Entity type:Individual
Prefix:
First Name:LATANDA
Middle Name:
Last Name:TERRY-GRAVES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8447 S GREEN ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-3208
Mailing Address - Country:US
Mailing Address - Phone:773-557-2743
Mailing Address - Fax:773-429-0300
Practice Address - Street 1:10046 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1926
Practice Address - Country:US
Practice Address - Phone:773-429-0300
Practice Address - Fax:773-429-5736
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL16329385101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool