Healthcare Provider Details

I. General information

NPI: 1184382566
Provider Name (Legal Business Name): KANDA THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2021
Last Update Date: 02/27/2023
Certification Date: 02/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W 191ST ST STE 6
MOKENA IL
60448-8730
US

IV. Provider business mailing address

9200 W 191ST ST STE 6
MOKENA IL
60448-8730
US

V. Phone/Fax

Practice location:
  • Phone: 815-421-9131
  • Fax:
Mailing address:
  • Phone: 815-421-9131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KRISTA RAATJES
Title or Position: PRESIDENT, LCSW
Credential: LCSW, RPLAYTHERAPIST
Phone: 815-421-9131