Healthcare Provider Details

I. General information

NPI: 1457649246
Provider Name (Legal Business Name): STICKNEY PUBLIC HEALTH DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2011
Last Update Date: 07/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6721 40TH ST
STICKNEY IL
60402-4174
US

IV. Provider business mailing address

6721 40TH ST
STICKNEY IL
60402-4174
US

V. Phone/Fax

Practice location:
  • Phone: 708-788-9100
  • Fax: 708-788-4856
Mailing address:
  • Phone: 708-788-9100
  • Fax: 708-788-4856

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 State

VIII. Authorized Official

Name: DR. CHISTOPHER GRUNOW
Title or Position: HEALTH DIRECTOR
Credential: PSY.D.
Phone: 708-424-9200