Healthcare Provider Details

I. General information

NPI: 1255739504
Provider Name (Legal Business Name): PAUL ANDREW KELVINGTON LCSW,LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2014
Last Update Date: 12/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

654 1/2 W OAKDALE AVE #1W
CHICAGO IL
60657-5370
US

IV. Provider business mailing address

654 1/2 W OAKDALE AVE #1W
CHICAGO IL
60657-5370
US

V. Phone/Fax

Practice location:
  • Phone: 773-666-3022
  • Fax:
Mailing address:
  • Phone: 773-666-3022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.009378
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.015592
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: