Provider Demographics
NPI:1801927702
Name:FERRELL, KEENAN (PSYD)
Entity type:Individual
Prefix:
First Name:KEENAN
Middle Name:
Last Name:FERRELL
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 1:5455 N SHERIDAN RD
Mailing Address - Street 2:1709
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1958
Mailing Address - Country:US
Mailing Address - Phone:773-944-5301
Mailing Address - Fax:773-944-5302
Practice Address - Street 1:5455 N SHERIDAN RD
Practice Address - Street 2:1709
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1958
Practice Address - Country:US
Practice Address - Phone:773-944-5301
Practice Address - Fax:773-944-5302
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00987103TC0700X
IN20041967A103TC0700X
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI15221Medicare ID - Type UnspecifiedMEDICARE PART B
IN232540AMedicare ID - Type UnspecifiedMEDICARE PART B
ILK21523Medicare ID - Type UnspecifiedMEDICARE PART B