Provider Demographics
NPI:1700869104
Name:BREITWISER, KENNETH TERRY (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:TERRY
Last Name:BREITWISER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1453 W RASCHER AVE
Mailing Address - Street 2:#1E
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1205
Mailing Address - Country:US
Mailing Address - Phone:773-561-3493
Mailing Address - Fax:
Practice Address - Street 1:50 EAST WASHINGTON
Practice Address - Street 2:ST. JAMES CATHEDRAL COUNSELING CENTER
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-2142
Practice Address - Country:US
Practice Address - Phone:312-252-9500
Practice Address - Fax:312-337-9243
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490133421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical