1215802509 NPI number — RILEY KATHLEEN CORNACCHINI R-DMT

Table of content: RILEY KATHLEEN CORNACCHINI R-DMT (NPI 1215802509)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215802509 NPI number — RILEY KATHLEEN CORNACCHINI R-DMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORNACCHINI
Provider First Name:
RILEY
Provider Middle Name:
KATHLEEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
R-DMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215802509
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1550 N CLARK ST APT 1001
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60610-3612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-565-7500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1802 W BERTEAU AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60613-6181
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-202-9121
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/07/2025

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225600000X , with the licence number:  3068 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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