Basic Information
| Provider Information | |||||||||
| NPI: | 1255987806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEWART | ||||||||
| FirstName: | KASHEENA | ||||||||
| MiddleName: | MONIQUE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 REVERE DR STE 120 | ||||||||
| Address2: | |||||||||
| City: | NORTHBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600628005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473069843 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1845 GRANDSTAND PL | ||||||||
| Address2: | |||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601236603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476950484 | ||||||||
| FaxNumber: | 8475311405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2019 | ||||||||
| LastUpdateDate: | 01/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.