Provider Demographics
NPI:1306330766
Name:BLAKENEY, KAITLIN (LPC, CRC)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:BLAKENEY
Suffix:
Gender:F
Credentials:LPC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10260 S BEVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1382
Mailing Address - Country:US
Mailing Address - Phone:815-295-7005
Mailing Address - Fax:
Practice Address - Street 1:11350 S LANGLEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-5126
Practice Address - Country:US
Practice Address - Phone:815-295-7005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2019-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.013763101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional