Healthcare Provider Details

I. General information

NPI: 1366381865
Provider Name (Legal Business Name): KELVIN CHIAGOZIE OBODOAKU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2026
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 E TOUHY AVE
DES PLAINES IL
60018-3303
US

IV. Provider business mailing address

841 W SUNNYSIDE AVE APT 103
CHICAGO IL
60640-7291
US

V. Phone/Fax

Practice location:
  • Phone: 630-590-5571
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: