Provider Demographics
NPI:1407090657
Name:GROW, CAROLYN A
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:A
Last Name:GROW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 N MARE BARN LN
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-1132
Mailing Address - Country:US
Mailing Address - Phone:630-543-6053
Mailing Address - Fax:
Practice Address - Street 1:975 MARTHA ST
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3414
Practice Address - Country:US
Practice Address - Phone:847-437-8070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-30
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.001209225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist