Provider Demographics
NPI:1366951709
Name:GRAHAM, MANDILYN RENICE (LCPC)
Entity type:Individual
Prefix:
First Name:MANDILYN
Middle Name:RENICE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:MANDILYN
Other - Middle Name:RENICE
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCPC
Mailing Address - Street 1:17485 EASTGATE DR
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60478-4640
Mailing Address - Country:US
Mailing Address - Phone:773-301-3640
Mailing Address - Fax:
Practice Address - Street 1:7770 PAINT CREEK DR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-6139
Practice Address - Country:US
Practice Address - Phone:773-301-3640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-28
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401222749101YP2500X
IL180.009581101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional