Healthcare Provider Details

I. General information

NPI: 1851960959
Provider Name (Legal Business Name): DEWAYNE LEAKES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2021
Last Update Date: 09/29/2026
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 W 61ST ST
CHICAGO IL
60621-2855
US

IV. Provider business mailing address

735 W 61ST ST
CHICAGO IL
60621-2855
US

V. Phone/Fax

Practice location:
  • Phone: 773-332-8381
  • Fax:
Mailing address:
  • Phone: 773-332-8381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: