Basic Information
Provider Information
NPI: 1003000662
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BAKER
FirstName: KATHLEEN
MiddleName: ANN
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: DIEHL
OtherFirstName: KATHLEEN
OtherMiddleName: ANN
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType: 5
Mailing Information
Address1: 1001 ROHLWING RD
Address2:  
City: ELK GROVE VILLAGE
State: IL
PostalCode: 600073217
CountryCode: US
TelephoneNumber: 8475248800
FaxNumber:  
Practice Location
Address1: 1001 ROHLWING RD
Address2:  
City: ELK GROVE VILLAGE
State: IL
PostalCode: 600073217
CountryCode: US
TelephoneNumber: 8475248800
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/28/2007
LastUpdateDate: 08/28/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YP2500X ILY Behavioral Health & Social Service ProvidersCounselorProfessional

No ID Information.


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