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General NPI Number Information
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NPI Number | 1902658586
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Entity Type | Organization
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Legal Business Name | PKC HEALTH SERVICE
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Dates
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Enumeration Date | 04/04/2024
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Last Update Date | 09/26/2024
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Provider Practice Location Address
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Address Line | 1521 OTTO BLVD
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City | CHICAGO HEIGHTS
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State | IL
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Zip | 60411-3875
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Country | US
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Telephone | 708-303-8816
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Fax |
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Provider Business Mailing Address
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Address Line | 18300 S HALSTED STE B #341
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City | GLENWOOD
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State | IL
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Zip | 60425
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Country | US
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Telephone | 708-303-8816
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | LASHONDA CROCKETT
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Credential |
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Telephone | 708-303-8816
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101200000X
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Taxonomy Name | Drama Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 2081P0301X
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Taxonomy Name | Brain Injury Medicine (Physical Medicine & Rehabilitation) Physician
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 2084B0040X
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Taxonomy Name | Behavioral Neurology & Neuropsychiatry Physician
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 221700000X
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Taxonomy Name | Art Therapist
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License Number |
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License Number State |
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Taxonomy #9
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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Taxonomy #10
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Taxonomy Code | 225800000X
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Taxonomy Name | Recreation Therapist
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License Number |
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License Number State |
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Taxonomy #11
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Taxonomy Code | 225A00000X
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Taxonomy Name | Music Therapist
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License Number |
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License Number State |
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Taxonomy #12
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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Taxonomy #13
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #14
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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Taxonomy #15
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Taxonomy Code | 2084P0301X
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Taxonomy Name | Brain Injury Medicine (Psychiatry & Neurology) Physician
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License Number |
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License Number State |
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