Basic Information
Provider Information | |||||||||
NPI: | 1073840740 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KGH CONSULTATION & TREATMENT, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KGH AUTISM SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1161 LAKE COOK RD | ||||||||
Address2: |   | ||||||||
City: | DEERFIELD | ||||||||
State: | IL | ||||||||
PostalCode: | 600155649 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8474985437 | ||||||||
FaxNumber: | 8474985438 | ||||||||
Practice Location | |||||||||
Address1: | 1161 LAKE COOK RD | ||||||||
Address2: |   | ||||||||
City: | DEERFIELD | ||||||||
State: | IL | ||||||||
PostalCode: | 600155649 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8474985437 | ||||||||
FaxNumber: | 8474985438 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/17/2009 | ||||||||
LastUpdateDate: | 03/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 04/23/2020 | ||||||||
NPIReactivationDate: | 05/11/2020 | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOEHNE | ||||||||
AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
AuthorizedOfficialMiddleName: | GARVEY | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8474985437 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MA,BCBA | ||||||||
NPICertificationDate: | 12/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC2200X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 106S00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP |   |   |   | 225X00000X | 612826 | WI | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 225X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 235Z00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 103K00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
No ID Information.