Provider Demographics
NPI:1912508292
Name:MALLER, GRANT
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:MALLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 REVERE DR STE 120
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-8005
Mailing Address - Country:US
Mailing Address - Phone:847-807-6647
Mailing Address - Fax:847-348-3706
Practice Address - Street 1:8008 E ARAPAHOE CT
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-6839
Practice Address - Country:US
Practice Address - Phone:847-807-6647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-19-94756106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician