Provider Demographics
NPI:1124440474
Name:KANNENWISCHER, MONICA
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:KANNENWISCHER
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 1:3033 OGDEN AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-1673
Mailing Address - Country:US
Mailing Address - Phone:815-577-3666
Mailing Address - Fax:630-983-0162
Practice Address - Street 1:3033 OGDEN AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-1673
Practice Address - Country:US
Practice Address - Phone:815-577-3666
Practice Address - Fax:630-983-0162
Is Sole Proprietor?:No
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208.000226106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist