Healthcare Provider Details

I. General information

NPI: 1881328276
Provider Name (Legal Business Name): KIMBERLY SKOCZELAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

542 BRISTOL LN
ELK GROVE VILLAGE IL
60007-3428
US

IV. Provider business mailing address

542 BRISTOL LN
ELK GROVE VILLAGE IL
60007-3428
US

V. Phone/Fax

Practice location:
  • Phone: 630-363-0319
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number32930
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.011246
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: