MEDICARE: KAITLIN BLAKENEY LPC, CRC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	178.013763	IL

General Provider Information

NPI Number	:	1306330766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLIN BLAKENEY LPC, CRC

Provider Business Mailing Address
First Line	:	10260 S BEVERLY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-1382
Country	:	US
Telephone Number	:	815-295-7005
Fax Number	:

Provider Business Practice Location Address
First Line	:	11350 S LANGLEY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60628-5126
Country	:	US
Telephone Number	:	815-295-7005
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2018
Last Update Date	:	03/03/2019

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