Healthcare Provider Details

I. General information

NPI: 1679180194
Provider Name (Legal Business Name): MRS. KIM ELLEN MCKINNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIM ELLEN RUETER

II. Dates (important events)

Enumeration Date: 09/29/2020
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 WINDSOR DR STE 111&113
OAK BROOK IL
60523-1536
US

IV. Provider business mailing address

3938 W 21ST ST
CHICAGO IL
60623-2810
US

V. Phone/Fax

Practice location:
  • Phone: 630-728-1744
  • Fax: 630-998-7029
Mailing address:
  • Phone: 312-399-0483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.021036
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: