Healthcare Provider Details

I. General information

NPI: 1417520347
Provider Name (Legal Business Name): SARA ANNE GROTH MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2269 N KEDZIE BLVD
CHICAGO IL
60647-2591
US

IV. Provider business mailing address

2313 W MCLEAN AVE APT 1E
CHICAGO IL
60647-4161
US

V. Phone/Fax

Practice location:
  • Phone: 312-819-7381
  • Fax:
Mailing address:
  • Phone: 708-218-8160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: