Provider Demographics
NPI: | 1750046108 |
---|---|
Name: | KENABU WELLNESS PLLC |
Entity Type: | Organization |
Organization Name: | KENABU WELLNESS PLLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | KENYA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BUTTS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LCSW |
Authorized Official - Phone: | 312-612-0264 |
Mailing Address - Street 1: | 818 E 63RD ST STE 123 |
Mailing Address - Street 2: | |
Mailing Address - City: | CHICAGO |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60637-3518 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 312-612-0264 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 816 E 63RD ST |
Practice Address - Street 2: | |
Practice Address - City: | CHICAGO |
Practice Address - State: | IL |
Practice Address - Zip Code: | 60637-3518 |
Practice Address - Country: | US |
Practice Address - Phone: | 312-612-0264 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2021-11-01 |
Last Update Date: | 2021-11-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |