Provider Demographics
NPI:1508626417
Name:KREATIVE KINNECTIONZ YOUTH OUTREACH INC.
Entity Type:Organization
Organization Name:KREATIVE KINNECTIONZ YOUTH OUTREACH INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH-BRENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-857-5143
Mailing Address - Street 1:4137 SAUK TRL STE 116
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1253
Mailing Address - Country:US
Mailing Address - Phone:773-746-2063
Mailing Address - Fax:
Practice Address - Street 1:4137 SAUK TRL STE 116
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-1253
Practice Address - Country:US
Practice Address - Phone:773-746-2063
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management