Healthcare Provider Details

I. General information

NPI: 1033616354
Provider Name (Legal Business Name): BRIGID MOIRE KELLY DAGENFIELD LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5419 W LAWRENCE AVE
CHICAGO IL
60630-3686
US

IV. Provider business mailing address

5615 W GIDDINGS ST
CHICAGO IL
60630-3213
US

V. Phone/Fax

Practice location:
  • Phone: 312-869-9899
  • Fax:
Mailing address:
  • Phone: 614-580-7349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180010908
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178011182
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: