Healthcare Provider Details

I. General information

NPI: 1306171525
Provider Name (Legal Business Name): MINDY KIRKTON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2009
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1813 W KIRBY AVE
CHAMPAIGN IL
61821-5410
US

IV. Provider business mailing address

528 COUNTY ROAD 1400 E
TOLONO IL
61880-9716
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-6039
  • Fax: 217-383-4081
Mailing address:
  • Phone: 217-840-0063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number149030878
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: