Healthcare Provider Details

I. General information

NPI: 1891245171
Provider Name (Legal Business Name): KENDRA LEIGH WENZEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KENDRA LEIGH CROSBY

II. Dates (important events)

Enumeration Date: 10/10/2016
Last Update Date: 10/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6601 N AVONDALE AVE
CHICAGO IL
60631-1572
US

IV. Provider business mailing address

2232 W BERWYN AVE 3
CHICAGO IL
60625-1149
US

V. Phone/Fax

Practice location:
  • Phone: 773-774-4444
  • Fax:
Mailing address:
  • Phone: 971-221-4611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.009903
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: