MEDICARE: DR. KELLY J BEHRENDS PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	180003498	IL
2	103TC0700X	Clinical Psychologist	071.007337	IL

General Provider Information

NPI Number	:	1598809113
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY J BEHRENDS PSYD

Provider Business Mailing Address
First Line	:	1248 AMERICAN WAY
Second Line	:	SUITE B
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048-3936
Country	:	US
Telephone Number	:	847-754-5570
Fax Number	:

Provider Business Practice Location Address
First Line	:	1248 AMERICAN WAY
Second Line	:	SUITE B
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048-3936
Country	:	US
Telephone Number	:	847-754-5570
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/16/2007
Last Update Date	:	08/28/2013

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