Healthcare Provider Details

I. General information

NPI: 1124419643
Provider Name (Legal Business Name): KEVIN CONNOLLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2015
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TIFFANY PT STE 110
BLOOMINGDALE IL
60108-2915
US

IV. Provider business mailing address

1617 LAKE AVE
WILMETTE IL
60091-1535
US

V. Phone/Fax

Practice location:
  • Phone: 773-981-2972
  • Fax:
Mailing address:
  • Phone: 773-981-2972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number180009277
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180009277
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180009277
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number180009277
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: