Healthcare Provider Details

I. General information

NPI: 1356647721
Provider Name (Legal Business Name): KAREN JEAN KEWLEY LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2011
Last Update Date: 02/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5016 N UNIVERSITY ST STE 109
PEORIA IL
61614-4763
US

IV. Provider business mailing address

710 BITTERSWEET AVE
GERMANTOWN HILLS IL
61548-8658
US

V. Phone/Fax

Practice location:
  • Phone: 309-573-4834
  • Fax:
Mailing address:
  • Phone: 309-922-1145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180007688
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: