Healthcare Provider Details

I. General information

NPI: 1649497462
Provider Name (Legal Business Name): KEITH RENFROE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17504 CARRIAGEWAY DR. SUITE B
HAZEL CREST IL
60429
US

IV. Provider business mailing address

9651 S. UNION
CHICAGO IL
60628-1016
US

V. Phone/Fax

Practice location:
  • Phone: 708-799-0300
  • Fax: 773-298-0110
Mailing address:
  • Phone: 773-298-0110
  • Fax: 773-298-0110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. KEITH RICHARD RENFROE
Title or Position: CEO
Credential: M.A.
Phone: 708-799-0300