Healthcare Provider Details

I. General information

NPI: 1508060690
Provider Name (Legal Business Name): KEENA L. SIMS DT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 01/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 200TH ST
LYNWOOD IL
60411-1503
US

IV. Provider business mailing address

2500 200TH ST
LYNWOOD IL
60411-1503
US

V. Phone/Fax

Practice location:
  • Phone: 708-856-1949
  • Fax:
Mailing address:
  • Phone: 708-856-1949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: