Healthcare Provider Details

I. General information

NPI: 1700320975
Provider Name (Legal Business Name): KIMBERLY CRUTCHER LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2016
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5445 N SHERIDAN RD APT 1215
CHICAGO IL
60640-7460
US

IV. Provider business mailing address

5445 N SHERIDAN RD APT 1215
CHICAGO IL
60640-7460
US

V. Phone/Fax

Practice location:
  • Phone: 615-403-9820
  • Fax:
Mailing address:
  • Phone: 615-403-9820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.010556
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number180.010556
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: