Provider Demographics
NPI:1124880067
Name:PENKETHMAN, KATE
Entity type:Individual
Prefix:
First Name:KATE
Middle Name:
Last Name:PENKETHMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4226 N WHIPPLE ST APT 3W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-2529
Mailing Address - Country:US
Mailing Address - Phone:732-456-4102
Mailing Address - Fax:
Practice Address - Street 1:1757 N KIMBALL AVE UNIT 202
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-4805
Practice Address - Country:US
Practice Address - Phone:732-456-4102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health