MEDICARE: AQUANETTA KRISTINE HART

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1427620004
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AQUANETTA KRISTINE HART

Provider Business Mailing Address
First Line	:	3950 N LAKE SHORE DR APT 826E
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-3434
Country	:	US
Telephone Number	:	219-718-0157
Fax Number	:

Provider Business Practice Location Address
First Line	:	2023 RIDGE RD UNIT 2NW
Second Line	:
City	:	HOMEWOOD
State	:	IL
Zip	:	60430-1786
Country	:	US
Telephone Number	:	708-580-6042
Fax Number	:

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

Provider Enumeration Date	:	07/13/2021
Last Update Date	:	07/13/2021

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