Healthcare Provider Details

I. General information

NPI: 1467389411
Provider Name (Legal Business Name): EMMA KIRKHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHADE KIRKHAM

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 S GALENA AVE
FREEPORT IL
61032-2517
US

IV. Provider business mailing address

1631 S GALENA AVE
FREEPORT IL
61032-2517
US

V. Phone/Fax

Practice location:
  • Phone: 815-391-1000
  • Fax:
Mailing address:
  • Phone: 815-391-1000
  • Fax: 815-720-4952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number209.033838
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: