Provider Demographics
NPI:1104337195
Name:AMANDA GABRIELLE KACENA, LLC
Entity type:Organization
Organization Name:AMANDA GABRIELLE KACENA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:GABRIELLE
Authorized Official - Last Name:KACENA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:312-590-7140
Mailing Address - Street 1:4101 BRENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-1373
Mailing Address - Country:US
Mailing Address - Phone:312-590-7140
Mailing Address - Fax:
Practice Address - Street 1:2005 VALPARAISO ST STE 106
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-3330
Practice Address - Country:US
Practice Address - Phone:312-590-7140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001619A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN39001619AOtherSTATE LICENSE