Healthcare Provider Details

I. General information

NPI: 1760956585
Provider Name (Legal Business Name): KESHONNA THOMAS LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2019
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2653 W OGDEN AVE
CHICAGO IL
60608-1647
US

IV. Provider business mailing address

10433 LONGWOOD LN APT 11
OAK LAWN IL
60453-4942
US

V. Phone/Fax

Practice location:
  • Phone: 773-257-6672
  • Fax:
Mailing address:
  • Phone: 773-257-6672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180018430
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180018430
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: