Provider Demographics
NPI:1134983455
Name:GRAY, LAURIE JANSEN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:JANSEN
Last Name:GRAY
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 1:1401 MERGANSER BLVD
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-8544
Mailing Address - Country:US
Mailing Address - Phone:618-806-4243
Mailing Address - Fax:
Practice Address - Street 1:1401 MERGANSER BLVD
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-8544
Practice Address - Country:US
Practice Address - Phone:618-806-4243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0109681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical