Provider Demographics
NPI:1649497462
Name:KEITH RENFROE
Entity type:Organization
Organization Name:KEITH RENFROE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:RENFROE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:708-799-0300
Mailing Address - Street 1:9651 S. UNION
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-1016
Mailing Address - Country:US
Mailing Address - Phone:773-298-0110
Mailing Address - Fax:773-298-0110
Practice Address - Street 1:17504 CARRIAGEWAY DR.
Practice Address - Street 2:SUITE B
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429
Practice Address - Country:US
Practice Address - Phone:708-799-0300
Practice Address - Fax:773-298-0110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty