Provider Demographics
NPI:1164962502
Name:GRANT, KIM DELAYNE
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:DELAYNE
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:KIM
Other - Middle Name:D
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:2625 BUTTERFIELD RD
Mailing Address - Street 2:SUITE 101N
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1234
Mailing Address - Country:US
Mailing Address - Phone:630-586-0900
Mailing Address - Fax:
Practice Address - Street 1:2625 BUTTERFIELD RD
Practice Address - Street 2:SUITE 101N
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1234
Practice Address - Country:US
Practice Address - Phone:630-586-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-05
Last Update Date:2017-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.009195103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical