Healthcare Provider Details

I. General information

NPI: 1851128375
Provider Name (Legal Business Name): GRACE KATHERINE TRYBOM LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MEDICAL CENTER DR
MONTICELLO IL
61856-2116
US

IV. Provider business mailing address

1000 MEDICAL CENTER DR
MONTICELLO IL
61856-2116
US

V. Phone/Fax

Practice location:
  • Phone: 217-762-1520
  • Fax:
Mailing address:
  • Phone: 217-762-1755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.114336
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149041284
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: