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General NPI Number Information
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NPI Number | 1316046386
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Entity Type | Organization
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Legal Business Name | CENTER FOR GRIEF RECOVERY AND SIBLING LOSS
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Dates
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Enumeration Date | 09/22/2006
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Last Update Date | 10/06/2009
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Provider Practice Location Address
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Address Line | 1263 W LOYOLA AVE
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City | CHICAGO
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State | IL
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Zip | 60626-5101
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Country | US
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Telephone | 773-274-4600
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Fax |
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Provider Business Mailing Address
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Address Line | 1263 W LOYOLA AVE
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City | CHICAGO
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State | IL
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Zip | 60626-5101
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Country | US
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Telephone | 773-274-4600
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. DAVID MICHAEL FIREMAN
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Credential | LCSW
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Telephone | 773-274-4600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149-006624
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License Number State | IL
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