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NPI Code Detail

MEDICARE: MS. KELLY DERR LCSW

MEDICARE: MS. KELLY DERR LCSW
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
11041C0700XClinical Social Worker149016583IL

General Provider Information

NPI Number : 1912468927
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. KELLY DERR LCSW
Provider Business Mailing Address
First Line : 425 N BROADWAY ST
Second Line :
City : COAL CITY
State : IL
Zip : 60416-1044
Country : US
Telephone Number : 815-584-7730
Fax Number :
Provider Business Practice Location Address
First Line : 9435 BORMET DR STE 5
Second Line :
City : MOKENA
State : IL
Zip : 60448-7401
Country : US
Telephone Number : 708-995-7226
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/31/2019
Last Update Date : 03/31/2019

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