Healthcare Provider Details

I. General information

NPI: 1508793514
Provider Name (Legal Business Name): JOSEPH KELLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 25087
CHICAGO IL
60625-8601
US

IV. Provider business mailing address

4534 N AVERS AVE
CHICAGO IL
60625-6306
US

V. Phone/Fax

Practice location:
  • Phone: 888-888-8888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149029964
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: