Healthcare Provider Details

I. General information

NPI: 1831594407
Provider Name (Legal Business Name): CENTER FOR PERSONAL GROWTH, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2014
Last Update Date: 02/24/2024
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 E SAINT CHARLES RD STE 212
CAROL STREAM IL
60188-2600
US

IV. Provider business mailing address

640 E SAINT CHARLES RD STE 212
CAROL STREAM IL
60188-2600
US

V. Phone/Fax

Practice location:
  • Phone: 630-791-0118
  • Fax: 630-708-7654
Mailing address:
  • Phone: 630-791-0118
  • Fax: 630-708-7654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.008385
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number071.008385
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. KIERA E LIEBICH
Title or Position: OFFICE MANAGER
Credential:
Phone: 630-791-0118