| Doctor Name: | DR. GWEN IRENE GRANT |
| NPI Number: | 1013397678 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | PSY.D. |
| License Number: | 071007699 |
| Business Practice Address: | 14953 S Van Dyke Rd Plainfield, IL - 605445804 |
| Business Phone Number: | 7736206512 |
| Business Fax Number: | |
| Mailing Address: | 17120 W 145th St, LOCKPORT |
| State: | IL |
| Postal Code: | 604412297 |
| Phone Number: | 7736206512 |
| Fax Number: | |
| NPI Enumeration Date: | 06/08/2015 |
| NPI Last Update Date: | 10/12/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | 071007699 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |