Healthcare Provider Details

I. General information

NPI: 1386161503
Provider Name (Legal Business Name): AIMEE KACKLEY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 CHURCH ST # 1W
EVANSTON IL
60201-3604
US

IV. Provider business mailing address

1112 CHURCH ST # 1W
EVANSTON IL
60201-3604
US

V. Phone/Fax

Practice location:
  • Phone: 312-237-1419
  • Fax:
Mailing address:
  • Phone: 312-237-1419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178013231
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number937396
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: