Healthcare Provider Details

I. General information

NPI: 1174779771
Provider Name (Legal Business Name): COMPREHENSIVE HEALTH AGENCY NURTURING GUEST ENERVATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2008
Last Update Date: 08/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14719 HALSTED ST
HARVEY IL
60426-1920
US

IV. Provider business mailing address

14719 HALSTED ST
HARVEY IL
60426-1920
US

V. Phone/Fax

Practice location:
  • Phone: 708-331-2679
  • Fax:
Mailing address:
  • Phone: 708-331-2679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.006944
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.106435
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036.109938
License Number StateIL

VIII. Authorized Official

Name: KIMBERLY KENNER WASH
Title or Position: DIRECTOR
Credential:
Phone: 708-331-2679