Provider Demographics
NPI:1568280683
Name:COOTE, KYNDAL
Entity type:Individual
Prefix:
First Name:KYNDAL
Middle Name:
Last Name:COOTE
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 1:1164 W MADISON ST UNIT 530
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3802
Mailing Address - Country:US
Mailing Address - Phone:336-508-0029
Mailing Address - Fax:
Practice Address - Street 1:4621 N RAVENSWOOD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4509
Practice Address - Country:US
Practice Address - Phone:773-413-9523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.114254104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker