Provider Demographics
NPI:1831594407
Name:CENTER FOR PERSONAL GROWTH, PLLC
Entity type:Organization
Organization Name:CENTER FOR PERSONAL GROWTH, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIERA
Authorized Official - Middle Name:E
Authorized Official - Last Name:LIEBICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-791-0118
Mailing Address - Street 1:640 E SAINT CHARLES RD STE 212
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-2600
Mailing Address - Country:US
Mailing Address - Phone:630-791-0118
Mailing Address - Fax:630-708-7654
Practice Address - Street 1:640 E SAINT CHARLES RD STE 212
Practice Address - Street 2:
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188-2600
Practice Address - Country:US
Practice Address - Phone:630-791-0118
Practice Address - Fax:630-708-7654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-25
Last Update Date:2024-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008385103TC2200X, 103TC0700X
103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL321707109001Medicaid