Provider Demographics
NPI:1992704225
Name:GRONAU, ROGER C (PHD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:C
Last Name:GRONAU
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 1:970 MCHENRY AVE
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7449
Mailing Address - Country:US
Mailing Address - Phone:815-455-7100
Mailing Address - Fax:815-455-3951
Practice Address - Street 1:527 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-3756
Practice Address - Country:US
Practice Address - Phone:815-338-9199
Practice Address - Fax:815-338-9205
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1957-057103T00000X
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05619771OtherBCBS
IL05619771OtherBCBS