Provider Demographics
NPI:1407680929
Name:KATHLEEN PENDERGAST LLC
Entity type:Organization
Organization Name:KATHLEEN PENDERGAST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PENDERGAST
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:773-217-8834
Mailing Address - Street 1:1564 N DAMEN AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2102
Mailing Address - Country:US
Mailing Address - Phone:733-217-8834
Mailing Address - Fax:
Practice Address - Street 1:2001 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5413
Practice Address - Country:US
Practice Address - Phone:773-217-8834
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KATHLEEN PENDERGAST LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty