Provider Demographics
NPI:1518599968
Name:BUTCHER, KENYATTA (HAIR LOSS SPECIALIST)
Entity Type:Individual
Prefix:MS
First Name:KENYATTA
Middle Name:
Last Name:BUTCHER
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 N KENMORE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2445
Mailing Address - Country:US
Mailing Address - Phone:773-931-8963
Mailing Address - Fax:
Practice Address - Street 1:8100 S STONY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-1734
Practice Address - Country:US
Practice Address - Phone:312-623-9966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management