Healthcare Provider Details

I. General information

NPI: 1992155352
Provider Name (Legal Business Name): KELLY HULL LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 10/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 S 6TH AVE CLC OFFICE
MAYWOOD IL
60153-1305
US

IV. Provider business mailing address

1118 N HARLEM AVE APT D
RIVER FOREST IL
60305-1559
US

V. Phone/Fax

Practice location:
  • Phone: 708-344-5536
  • Fax: 708-344-5535
Mailing address:
  • Phone: 312-399-7065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180011054
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178009412
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: