Basic Information
| Provider Information | |||||||||
| NPI: | 1275947152 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEFINA | ||||||||
| FirstName: | KENNA | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 N 2ND ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633012832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362241000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 141 COMMUNICATION DR | ||||||||
| Address2: | |||||||||
| City: | HANNIBAL | ||||||||
| State: | MO | ||||||||
| PostalCode: | 634013670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736031460 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2014 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 376001106007 | 05 | IL | MEDICAID | 376001106006 | 05 | IL | MEDICAID |