MEDICARE: EARLE RONALD KELWYN GROSVENOR MA, LPC

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	178.005976	IL

General Provider Information

NPI Number	:	1740554567
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EARLE RONALD KELWYN GROSVENOR MA, LPC

Provider Business Mailing Address
First Line	:	3420 W PETERSON AVE
Second Line	:	SUITE 6
City	:	CHICAGO
State	:	IL
Zip	:	60659-3418
Country	:	US
Telephone Number	:	312-527-1290
Fax Number	:	773-267-6113

Provider Business Practice Location Address
First Line	:	3420 W PETERSON AVE
Second Line	:	SUITE 6
City	:	CHICAGO
State	:	IL
Zip	:	60659-3418
Country	:	US
Telephone Number	:	312-527-1290
Fax Number	:	773-267-6113

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

Provider Enumeration Date	:	02/24/2012
Last Update Date	:	02/24/2012

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