Provider Demographics
NPI:1184335606
Name:DOCTOR, KEIONA (LSW)
Entity type:Individual
Prefix:
First Name:KEIONA
Middle Name:
Last Name:DOCTOR
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7027 N GLENWOOD AVE APT 2S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-2868
Mailing Address - Country:US
Mailing Address - Phone:620-803-9062
Mailing Address - Fax:
Practice Address - Street 1:721 S QUENTIN RD
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067-6778
Practice Address - Country:US
Practice Address - Phone:847-354-7490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.1096101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health