Provider Demographics
NPI:1336658848
Name:CRYSTAL KANNANKERIL, PSYD LLC
Entity Type:Organization
Organization Name:CRYSTAL KANNANKERIL, PSYD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER AND SOLE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:KANNANKERIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-834-3076
Mailing Address - Street 1:30 N MICHIGAN AVE STE 502
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3834
Mailing Address - Country:US
Mailing Address - Phone:312-834-3076
Mailing Address - Fax:
Practice Address - Street 1:30 N MICHIGAN AVE STE 502
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3834
Practice Address - Country:US
Practice Address - Phone:312-834-3076
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008430261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)