Healthcare Provider Details

I. General information

NPI: 1689623787
Provider Name (Legal Business Name): STEVEN LARRY GRYLL PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N SAINT CLAIR ST SUITE 1785
CHICAGO IL
60611-2927
US

IV. Provider business mailing address

676 N SAINT CLAIR ST SUITE 1785
CHICAGO IL
60611-2927
US

V. Phone/Fax

Practice location:
  • Phone: 312-649-1054
  • Fax: 312-573-1919
Mailing address:
  • Phone: 312-649-1054
  • Fax: 312-573-1919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: