Provider Demographics
NPI:1497455398
Name:KENTRIS, ADA LOUISE
Entity Type:Individual
Prefix:
First Name:ADA
Middle Name:LOUISE
Last Name:KENTRIS
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 1:4331 LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-2404
Mailing Address - Country:US
Mailing Address - Phone:708-748-1951
Mailing Address - Fax:
Practice Address - Street 1:915 LAURA LN
Practice Address - Street 2:
Practice Address - City:SAUK VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60411-5097
Practice Address - Country:US
Practice Address - Phone:708-733-3671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health