Healthcare Provider Details

I. General information

NPI: 1902658586
Provider Name (Legal Business Name): PKC HEALTH SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2024
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 OTTO BLVD
CHICAGO HEIGHTS IL
60411-3875
US

IV. Provider business mailing address

18300 S HALSTED STE B #341
GLENWOOD IL
60425
US

V. Phone/Fax

Practice location:
  • Phone: 708-303-8816
  • Fax:
Mailing address:
  • Phone: 708-303-8816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101200000X
TaxonomyDrama Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2081P0301X
TaxonomyBrain Injury Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 14
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 15
Primary TaxonomyY
Taxonomy Code2084P0301X
TaxonomyBrain Injury Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: LASHONDA CROCKETT
Title or Position: PRESIDENT
Credential:
Phone: 708-303-8816