Provider Demographics
NPI:1174030381
Name:GREENWELL, KRISTIAN SHUMATE
Entity Type:Individual
Prefix:
First Name:KRISTIAN
Middle Name:SHUMATE
Last Name:GREENWELL
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 1:2720 W CORTLAND ST APT 105
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5182
Mailing Address - Country:US
Mailing Address - Phone:270-303-1313
Mailing Address - Fax:
Practice Address - Street 1:1739 N ELSTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-1544
Practice Address - Country:US
Practice Address - Phone:773-687-9241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-09
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist