Provider Demographics
NPI:1851870406
Name:WAKEFUL PRACTICE, LLC
Entity type:Organization
Organization Name:WAKEFUL PRACTICE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:B
Authorized Official - Last Name:KALLENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:312-625-3373
Mailing Address - Street 1:4018 N LAWLER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-1733
Mailing Address - Country:US
Mailing Address - Phone:312-625-3373
Mailing Address - Fax:
Practice Address - Street 1:4054 N LINCOLN AVE STE 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-3144
Practice Address - Country:US
Practice Address - Phone:312-625-3373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-13
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)