Healthcare Provider Details

I. General information

NPI: 1417763707
Provider Name (Legal Business Name): ROBERT KENYON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2024
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 W CERMAK RD
CHICAGO IL
60608-4204
US

IV. Provider business mailing address

1801 WATERMARK DR STE 200
COLUMBUS OH
43215-7088
US

V. Phone/Fax

Practice location:
  • Phone: 773-596-9045
  • Fax:
Mailing address:
  • Phone: 614-487-8758
  • Fax: 614-487-8759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: