Provider Demographics
NPI:1629185475
Name:GROENENDAL, EDWARD (MA)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:
Last Name:GROENENDAL
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 WEST EASTMAN STREET
Mailing Address - Street 2:SUITE 305D
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-5938
Mailing Address - Country:US
Mailing Address - Phone:847-899-8370
Mailing Address - Fax:630-830-2463
Practice Address - Street 1:116 W EASTMAN ST
Practice Address - Street 2:SUITE 202A
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-5938
Practice Address - Country:US
Practice Address - Phone:847-899-8370
Practice Address - Fax:630-830-2463
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004527101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional