Healthcare Provider Details

I. General information

NPI: 1609520865
Provider Name (Legal Business Name): VICTORIA LYNN KEARNEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICTORIA GLASGOW

II. Dates (important events)

Enumeration Date: 02/07/2022
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 S LOMBARD ST
MAHOMET IL
61853-9202
US

IV. Provider business mailing address

2125 S NEIL ST
CHAMPAIGN IL
61820-7266
US

V. Phone/Fax

Practice location:
  • Phone: 217-352-0200
  • Fax: 217-607-1139
Mailing address:
  • Phone: 217-352-0200
  • Fax: 217-607-1139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.032074
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: