Provider Demographics
NPI:1942312665
Name:GRODMAN, JOSEPH E (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:E
Last Name:GRODMAN
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 1:200 WEST SUPERIOR
Mailing Address - Street 2:SUITE #403
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610
Mailing Address - Country:US
Mailing Address - Phone:312-944-2922
Mailing Address - Fax:
Practice Address - Street 1:200 WEST SUPERIOR
Practice Address - Street 2:SUITE #403
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610
Practice Address - Country:US
Practice Address - Phone:312-944-2922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical