Healthcare Provider Details

I. General information

NPI: 1942725841
Provider Name (Legal Business Name): KATHERINE ELIZABETH KELLY LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2017
Last Update Date: 08/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10735 S CICERO AVE
OAK LAWN IL
60453-5400
US

IV. Provider business mailing address

10735 S CICERO AVE
OAK LAWN IL
60453-5400
US

V. Phone/Fax

Practice location:
  • Phone: 708-424-0001
  • Fax:
Mailing address:
  • Phone: 708-424-0001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.011067
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: