Healthcare Provider Details

I. General information

NPI: 1740677780
Provider Name (Legal Business Name): KELSEY LOPEZ MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELSEY BODINE

II. Dates (important events)

Enumeration Date: 04/16/2015
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24402 W LOCKPORT ST STE 215
PLAINFIELD IL
60544-4204
US

IV. Provider business mailing address

6745 PINE LAKE DR
TINLEY PARK IL
60477-4935
US

V. Phone/Fax

Practice location:
  • Phone: 630-621-5824
  • Fax: 815-230-3652
Mailing address:
  • Phone: 630-244-5717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.011032
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: