Provider Demographics
NPI:1013414150
Name:GRO COMMUNITY
Entity Type:Organization
Organization Name:GRO COMMUNITY
Other - Org Name:GRO COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLORY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:773-253-8385
Mailing Address - Street 1:259 E 115TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-5014
Mailing Address - Country:US
Mailing Address - Phone:618-203-4368
Mailing Address - Fax:
Practice Address - Street 1:259 E 115TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-5014
Practice Address - Country:US
Practice Address - Phone:618-203-4368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-06
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QC1500X
IL261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health