Provider Demographics
NPI:1417625625
Name:BARWEGEN, KEARSTON
Entity Type:Individual
Prefix:
First Name:KEARSTON
Middle Name:
Last Name:BARWEGEN
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 1:5113 S HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4119
Mailing Address - Country:US
Mailing Address - Phone:708-374-7891
Mailing Address - Fax:
Practice Address - Street 1:5113 S HARPER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4119
Practice Address - Country:US
Practice Address - Phone:708-374-7891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009692103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty