Healthcare Provider Details

I. General information

NPI: 1871068783
Provider Name (Legal Business Name): KELSEY LYNN MORA CCLS, LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2018
Last Update Date: 12/30/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CENTRAL AVE STE 250
NORTHFIELD IL
60093-3024
US

IV. Provider business mailing address

400 CENTRAL AVE STE 250
NORTHFIELD IL
60093-3024
US

V. Phone/Fax

Practice location:
  • Phone: 402-650-0656
  • Fax:
Mailing address:
  • Phone: 847-231-2021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.014683
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number21412
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: