Provider Demographics
NPI:1376716506
Name:GROT, JAMES STEPHAN
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:STEPHAN
Last Name:GROT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 SPANGLER CT
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-9037
Mailing Address - Country:US
Mailing Address - Phone:815-652-3343
Mailing Address - Fax:
Practice Address - Street 1:500 ANCHOR RD
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-8829
Practice Address - Country:US
Practice Address - Phone:815-288-6691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical