Healthcare Provider Details

I. General information

NPI: 1023666120
Provider Name (Legal Business Name): MESPHINA KUDOWOR MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2019
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3324 W NORTH AVE
CHICAGO IL
60647-4935
US

IV. Provider business mailing address

3324 W NORTH AVE
CHICAGO IL
60647-4935
US

V. Phone/Fax

Practice location:
  • Phone: 773-661-6657
  • Fax:
Mailing address:
  • Phone: 773-661-6657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.018661
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.015525
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: