Healthcare Provider Details

I. General information

NPI: 1639667272
Provider Name (Legal Business Name): KATIE LYNN CUNNINGHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7234 W NORTH AVE STE 208
CHICAGO IL
60707-4202
US

IV. Provider business mailing address

7234 W NORTH AVE STE 208
CHICAGO IL
60707-4202
US

V. Phone/Fax

Practice location:
  • Phone: 708-505-6165
  • Fax:
Mailing address:
  • Phone: 708-505-6165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.014430
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: