Provider Demographics
NPI:1376878710
Name:KIENOW, AMY LEE
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:LEE
Last Name:KIENOW
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 1:4028 N PAULINA ST
Mailing Address - Street 2:APT 1A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613
Mailing Address - Country:US
Mailing Address - Phone:605-380-0349
Mailing Address - Fax:
Practice Address - Street 1:5235 N. CLARK
Practice Address - Street 2:STE 2N
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-3334
Practice Address - Country:US
Practice Address - Phone:605-380-0349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-02
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IL149.0153451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health