Healthcare Provider Details

I. General information

NPI: 1770046021
Provider Name (Legal Business Name): KATELYN MCKENZIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 12/10/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 W GRAND AVE STE 207
ELMHURST IL
60126-1025
US

IV. Provider business mailing address

650 W GRAND AVE STE 207
ELMHURST IL
60126-1025
US

V. Phone/Fax

Practice location:
  • Phone: 844-263-1613
  • Fax: 844-263-1612
Mailing address:
  • Phone: 844-263-1613
  • Fax: 844-263-1612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: