Healthcare Provider Details

I. General information

NPI: 1750689949
Provider Name (Legal Business Name): MICHAEL EDWARD KELL R.N, L.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2011
Last Update Date: 03/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6808 N WAYNE AVE
CHICAGO IL
60626-3718
US

IV. Provider business mailing address

2737 W LUNT AVE
CHICAGO IL
60645-3005
US

V. Phone/Fax

Practice location:
  • Phone: 773-537-3615
  • Fax: 773-537-3466
Mailing address:
  • Phone: 773-973-2126
  • Fax: 773-537-3466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.011523
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number041.173569
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: