Healthcare Provider Details

I. General information

NPI: 1154152718
Provider Name (Legal Business Name): KDE & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2024
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 173RD ST
HAMMOND IN
46324-2564
US

IV. Provider business mailing address

257 173RD ST
HAMMOND IN
46324-2564
US

V. Phone/Fax

Practice location:
  • Phone: 219-554-9158
  • Fax:
Mailing address:
  • Phone: 219-554-9158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KENNISE D EATON
Title or Position: CEO
Credential: LCPC, LMHC
Phone: 219-554-9158