Provider Demographics
NPI:1154152718
Name:KDE & WELLNESS
Entity type:Organization
Organization Name:KDE & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENNISE
Authorized Official - Middle Name:D
Authorized Official - Last Name:EATON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, LMHC
Authorized Official - Phone:219-554-9158
Mailing Address - Street 1:257 173RD ST
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46324-2564
Mailing Address - Country:US
Mailing Address - Phone:219-554-9158
Mailing Address - Fax:
Practice Address - Street 1:257 173RD ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46324-2564
Practice Address - Country:US
Practice Address - Phone:219-554-9158
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)