Provider Demographics
NPI:1548994767
Name:KIDNECTIVITY,LLC
Entity type:Organization
Organization Name:KIDNECTIVITY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-748-8733
Mailing Address - Street 1:600 WAUKEGAN RD STE 132
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-1249
Mailing Address - Country:US
Mailing Address - Phone:847-748-8733
Mailing Address - Fax:847-739-7164
Practice Address - Street 1:600 WAUKEGAN RD STE 132
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1249
Practice Address - Country:US
Practice Address - Phone:847-748-8733
Practice Address - Fax:847-739-7164
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIDNECTIVITY,LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001710375969Medicaid