Provider Demographics
NPI:1902489552
Name:PELZER, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:PELZER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:LETHIOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3446 N DAMEN AVE # 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6106
Mailing Address - Country:US
Mailing Address - Phone:815-228-0782
Mailing Address - Fax:
Practice Address - Street 1:540 W FRONTAGE RD STE 2215
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-1228
Practice Address - Country:US
Practice Address - Phone:847-848-0697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-02
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.016306101YP2500X
IL180.014034101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional