Provider Demographics
NPI:1740554567
Name:GROSVENOR, EARLE RONALD KELWYN (MA, LPC)
Entity type:Individual
Prefix:
First Name:EARLE
Middle Name:RONALD KELWYN
Last Name:GROSVENOR
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3420 W PETERSON AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-3418
Mailing Address - Country:US
Mailing Address - Phone:312-527-1290
Mailing Address - Fax:773-267-6113
Practice Address - Street 1:3420 W PETERSON AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3418
Practice Address - Country:US
Practice Address - Phone:312-527-1290
Practice Address - Fax:773-267-6113
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-24
Last Update Date:2012-02-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL178.005976101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional