Mandilyn Renice Graham, LCPC

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

License

180.009581 Issued in IL

Practice address

7770 Paint Creek Dr
Ypsilanti, MI 48197-6139

Phone

(773) 301-3640

NPI assigned

Sep 28, 2017

Last updated

Feb 16, 2023By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other names 1

• Mandilyn Renice Green Other name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1506556800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1676505600000",
    "number": "1366951709",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "17485 EASTGATE DR",
            "city": "COUNTRY CLUB HILLS",
            "state": "IL",
            "postal_code": "604784640",
            "telephone_number": "773-301-3640"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7770 PAINT CREEK DR",
            "city": "YPSILANTI",
            "state": "MI",
            "postal_code": "481976139",
            "telephone_number": "773-301-3640"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GRAHAM",
        "first_name": "MANDILYN",
        "middle_name": "RENICE",
        "credential": "LCPC",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2017-09-28",
        "last_updated": "2023-02-16",
        "certification_date": "2023-02-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "MI",
            "license": "6401222749",
            "primary": false
        },
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "IL",
            "license": "180.009581",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "MANDILYN",
            "last_name": "GREEN",
            "middle_name": "RENICE",
            "credential": "LCPC",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

• Andrea Graff
• Ian A Grager
• Jenee Graham
• Jenna Graham
• Kelly Graham
• Sandra Tollinger Graham, PT
• Derek Wayne Gramza
• Adam Douglas Grant, CPRC, CPSS, CHW
• Sherry Lynne Grant
• Thomas R Gravelyn, M.D.

• Professional Counselor in Ypsilanti, MI
• Providers in Ypsilanti, MI by specialty
• Professional Counselor in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 16, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.