Provider Demographics
NPI:1689623787
Name:GRYLL, STEVEN LARRY (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:LARRY
Last Name:GRYLL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 N SAINT CLAIR ST
Mailing Address - Street 2:SUITE 1785
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2927
Mailing Address - Country:US
Mailing Address - Phone:312-649-1054
Mailing Address - Fax:312-573-1919
Practice Address - Street 1:676 N SAINT CLAIR ST
Practice Address - Street 2:SUITE 1785
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2927
Practice Address - Country:US
Practice Address - Phone:312-649-1054
Practice Address - Fax:312-573-1919
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5632281OtherAETNA
016-72606OtherBLUE CROSS BLUE SHIELD
322170Medicare ID - Type Unspecified