Basic Information
| Provider Information | |||||||||
| NPI: | 1316212251 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNIEBREW | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | HEATHERE | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3010 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | WAUKEGAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600852321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473777950 | ||||||||
| FaxNumber: | 8479845635 | ||||||||
| Practice Location | |||||||||
| Address1: | 24647 N MILWAUKEE AVE | ||||||||
| Address2: | |||||||||
| City: | VERNON HILLS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600611567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473777950 | ||||||||
| FaxNumber: | 8479845635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2012 | ||||||||
| LastUpdateDate: | 03/10/2012 | ||||||||
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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 | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041S0200X | N | Behavioral Health & Social Service Providers | Social Worker | School |
No ID Information.