Healthcare Provider Details

I. General information

NPI: 1275199846
Provider Name (Legal Business Name): GROLL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2019
Last Update Date: 06/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 N NORTHWEST HWY STE 305C
PARK RIDGE IL
60068-1469
US

IV. Provider business mailing address

4707 N OKETO AVE
HARWOOD HEIGHTS IL
60706-4612
US

V. Phone/Fax

Practice location:
  • Phone: 708-925-3540
  • Fax: 708-925-3540
Mailing address:
  • Phone: 708-925-3540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANITA GROLL
Title or Position: PRESIDENT
Credential:
Phone: 708-925-3540