MEDICARE: KENIKA LIONTA CARTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist		IL

General Provider Information

NPI Number	:	1144883943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENIKA LIONTA CARTER

Provider Business Mailing Address
First Line	:	13246 S PRAIRE AV
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60827-1246
Country	:	US
Telephone Number	:	773-982-4334
Fax Number	:

Provider Business Practice Location Address
First Line	:	13246 S PRAIRE AV
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60827-1246
Country	:	US
Telephone Number	:	773-982-4334
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2019
Last Update Date	:	04/17/2019

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Directions to “ KENIKA LIONTA CARTER ” Practice Location

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