Healthcare Provider Details

I. General information

NPI: 1891526489
Provider Name (Legal Business Name): KEVIN T WOLTER LCSW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2024
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6830 CARPENTER ST
DOWNERS GROVE IL
60516-3435
US

IV. Provider business mailing address

6830 CARPENTER ST
DOWNERS GROVE IL
60516-3435
US

V. Phone/Fax

Practice location:
  • Phone: 224-406-2056
  • Fax:
Mailing address:
  • Phone: 224-406-2056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KEVIN T WOLTER
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 224-406-2056