Healthcare Provider Details

I. General information

NPI: 1912861782
Provider Name (Legal Business Name): KENDRA CALLISON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

848 W EASTMAN ST STE 103
CHICAGO IL
60642-2635
US

IV. Provider business mailing address

515 W BRIAR PL APT 503
CHICAGO IL
60657-4627
US

V. Phone/Fax

Practice location:
  • Phone: 312-702-2303
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: