Provider Demographics
NPI:1932515822
Name:MALENA, KEAJUANIS (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KEAJUANIS
Middle Name:
Last Name:MALENA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 LAWRENCE LN
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-2933
Mailing Address - Country:US
Mailing Address - Phone:817-793-1011
Mailing Address - Fax:
Practice Address - Street 1:16162 ELLIS AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-1700
Practice Address - Country:US
Practice Address - Phone:817-793-1011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-11
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008853103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist