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General NPI Number Information
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NPI Number | 1932942497
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Entity Type | Organization
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Legal Business Name | RADICALLYBLENDED SERVICES
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Dates
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Enumeration Date | 06/13/2024
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Last Update Date | 11/14/2024
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Provider Practice Location Address
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Address Line | 5113 S HARPER AVE STE 2C
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City | CHICAGO
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State | IL
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Zip | 60615-4119
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Country | US
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Telephone | 872-763-4405
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Fax |
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Provider Business Mailing Address
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Address Line | 5113 S HARPER AVE STE 2C
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City | CHICAGO
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State | IL
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Zip | 60615-4119
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Country | US
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Telephone | 872-763-4405
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KEISHA J WALKER MATHEW
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Credential | LCSW
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Telephone | 872-763-4405
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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