Provider Demographics
NPI:1962092981
Name:GRAY, SUZETTE (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:SUZETTE
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2212 W GRACE ST
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-4591
Mailing Address - Country:US
Mailing Address - Phone:815-258-1868
Mailing Address - Fax:
Practice Address - Street 1:2212 W GRACE ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-4591
Practice Address - Country:US
Practice Address - Phone:815-258-1868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-23
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490185931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical