Healthcare Provider Details

I. General information

NPI: 1609712405
Provider Name (Legal Business Name): KC COUNSELING SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3921 PINTAIL DR
SPRINGFIELD IL
62711-6738
US

IV. Provider business mailing address

3921 PINTAIL DR
SPRINGFIELD IL
62711-6738
US

V. Phone/Fax

Practice location:
  • Phone: 217-786-8361
  • Fax: 217-775-0757
Mailing address:
  • Phone: 217-786-8361
  • Fax: 217-775-0757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KYNDA C CANADA
Title or Position: LCSW
Credential:
Phone: 217-299-1099