Healthcare Provider Details

I. General information

NPI: 1033079694
Provider Name (Legal Business Name): HAWK MOTH HEALING, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2025
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 W. NORTH SHORE AVENUE APT. 2
CHICAGO IL
60626
US

IV. Provider business mailing address

1402 W NORTH SHORE AVE APT 2
CHICAGO IL
60626-6828
US

V. Phone/Fax

Practice location:
  • Phone: 724-712-4268
  • Fax:
Mailing address:
  • Phone: 724-712-4268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KYAH HAWK
Title or Position: OWNER/ PRESIDENT
Credential:
Phone: 724-712-4268