Provider Demographics
NPI:1639054190
Name:GRAY, LISA
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 W 63RD ST FL 4
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60621-1917
Mailing Address - Country:US
Mailing Address - Phone:877-926-3936
Mailing Address - Fax:
Practice Address - Street 1:815 W 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-1917
Practice Address - Country:US
Practice Address - Phone:877-926-3936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-06
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL84-5111204171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor