Healthcare Provider Details

I. General information

NPI: 1790390722
Provider Name (Legal Business Name): SOPHIA MARIA KECALA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 W NORTH AVE
ELMHURST IL
60126-2135
US

IV. Provider business mailing address

16561 135TH ST
LEMONT IL
60439-4717
US

V. Phone/Fax

Practice location:
  • Phone: 630-279-3222
  • Fax: 630-279-3230
Mailing address:
  • Phone: 630-624-5427
  • Fax: 630-279-3230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number36-060984
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: