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NPI Code Detail

MEDICARE: KATHLEEN GRANHOLM

MEDICARE: KATHLEEN GRANHOLM
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
1104100000XSocial Worker

General Provider Information

NPI Number : 1558090308
Entity Type Code : Individual
Provider Name (Legal Business Name) : KATHLEEN GRANHOLM
Provider Business Mailing Address
First Line : 6639 N KEDZIE AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60645-4161
Country : US
Telephone Number : 773-765-3123
Fax Number :
Provider Business Practice Location Address
First Line : 6639 N KEDZIE AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60645-4161
Country : US
Telephone Number : 773-765-3123
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/07/2022
Last Update Date : 06/07/2022

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Directions to “ KATHLEEN GRANHOLM ” Practice Location

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