Healthcare Provider Details

I. General information

NPI: 1134045925
Provider Name (Legal Business Name): KELLY KATHERINE SISSON-SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6232 N PULASKI RD STE 400
CHICAGO IL
60646-5133
US

IV. Provider business mailing address

1455 W FARRAGUT AVE APT 3E
CHICAGO IL
60640-2286
US

V. Phone/Fax

Practice location:
  • Phone: 312-725-3093
  • Fax:
Mailing address:
  • Phone: 847-997-5376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.018328
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: