Provider Demographics
NPI:1740502475
Name:HATTISBURG, KEHINDE A
Entity type:Individual
Prefix:
First Name:KEHINDE
Middle Name:A
Last Name:HATTISBURG
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 1:913 E 54TH ST
Mailing Address - Street 2:#206
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-5019
Mailing Address - Country:US
Mailing Address - Phone:773-493-4000
Mailing Address - Fax:
Practice Address - Street 1:913 E 54TH ST
Practice Address - Street 2:#206
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-5019
Practice Address - Country:US
Practice Address - Phone:773-493-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.010211235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist