Healthcare Provider Details

I. General information

NPI: 1588094403
Provider Name (Legal Business Name): KENNETH KESSLER PH.D., MSCP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2013
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 WILLOW SPRINGS RD STE 120
LA GRANGE HIGHLANDS IL
60525-6540
US

IV. Provider business mailing address

PO BOX 695
MUNDELEIN IL
60060-0695
US

V. Phone/Fax

Practice location:
  • Phone: 708-579-0974
  • Fax:
Mailing address:
  • Phone: 708-579-0974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number074-000015
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071-005277
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: