Provider Demographics
NPI:1538319579
Name:CRAIG, KANEESHA
Entity Type:Individual
Prefix:
First Name:KANEESHA
Middle Name:
Last Name:CRAIG
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 1:12644 S UNION AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-7022
Mailing Address - Country:US
Mailing Address - Phone:773-842-9455
Mailing Address - Fax:
Practice Address - Street 1:12644 S UNION AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-7022
Practice Address - Country:US
Practice Address - Phone:773-842-9455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-26
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005809101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional