Provider Demographics
NPI:1083235824
Name:BHAKTA, KARISHMA JAYESHBHAI
Entity Type:Individual
Prefix:
First Name:KARISHMA
Middle Name:JAYESHBHAI
Last Name:BHAKTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5105 S HARPER AVE UNIT 301
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4357
Mailing Address - Country:US
Mailing Address - Phone:559-759-1277
Mailing Address - Fax:
Practice Address - Street 1:1800 RAVINIA PL
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3761
Practice Address - Country:US
Practice Address - Phone:559-759-1277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-04
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150104354104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL150104354OtherASWB