Healthcare Provider Details

I. General information

NPI: 1417828104
Provider Name (Legal Business Name): KATRINA ANN KING CARDENAS RPRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATRINA KING RPRS

II. Dates (important events)

Enumeration Date: 09/15/2025
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10656 GOLDEN GATE AVE
HUNTLEY IL
60142-4027
US

IV. Provider business mailing address

10656 GOLDEN GATE AVE
HUNTLEY IL
60142-4027
US

V. Phone/Fax

Practice location:
  • Phone: 540-272-8868
  • Fax:
Mailing address:
  • Phone: 540-272-8868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number45346
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number0735001121
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: