MEDICARE: KELLY GRILL-COOPER MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	180008099	IL

General Provider Information

NPI Number	:	1164688578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY GRILL-COOPER MS

Provider Business Mailing Address
First Line	:	3238 MARBILL FARM RD
Second Line	:
City	:	MONTGOMERY
State	:	IL
Zip	:	60538-3342
Country	:	US
Telephone Number	:	440-821-5772
Fax Number	:

Provider Business Practice Location Address
First Line	:	3238 MARBILL FARM RD
Second Line	:
City	:	MONTGOMERY
State	:	IL
Zip	:	60538-3342
Country	:	US
Telephone Number	:	440-821-5772
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2008
Last Update Date	:	06/19/2013

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