Healthcare Provider Details

I. General information

NPI: 1093704462
Provider Name (Legal Business Name): MRS. GRANVIA CHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 DEMPSTER ST
PARK RIDGE IL
60068-1110
US

IV. Provider business mailing address

1784 CENTRAL RD
GLENVIEW IL
60025-4227
US

V. Phone/Fax

Practice location:
  • Phone: 847-318-9330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number056-005918
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: