Healthcare Provider Details

I. General information

NPI: 1770119935
Provider Name (Legal Business Name): TAKENYA WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2020
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13136 WESTERN AVE
BLUE ISLAND IL
60406-2423
US

IV. Provider business mailing address

13136 WESTERN AVE
BLUE ISLAND IL
60406-2423
US

V. Phone/Fax

Practice location:
  • Phone: 708-858-8946
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: