Provider Demographics
NPI:1790390722
Name:KECALA, SOPHIA MARIA
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:MARIA
Last Name:KECALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16561 135TH ST
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-4717
Mailing Address - Country:US
Mailing Address - Phone:630-624-5427
Mailing Address - Fax:630-279-3230
Practice Address - Street 1:533 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2135
Practice Address - Country:US
Practice Address - Phone:630-279-3222
Practice Address - Fax:630-279-3230
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-0609842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry