Healthcare Provider Details

I. General information

NPI: 1619368693
Provider Name (Legal Business Name): NANCYKKINLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2015
Last Update Date: 02/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 HILLTOP ST
COLONA IL
61241-8819
US

IV. Provider business mailing address

105 HILLTOP ST
COLONA IL
61241-8819
US

V. Phone/Fax

Practice location:
  • Phone: 309-945-7969
  • Fax: 309-441-6085
Mailing address:
  • Phone: 309-945-7969
  • Fax: 309-441-6085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number149.010286
License Number StateIL

VIII. Authorized Official

Name: MS. NANCY KERR KINLEY
Title or Position: THERAPIST
Credential: LCSW
Phone: 309-945-7969