Healthcare Provider Details

I. General information

NPI: 1457018038
Provider Name (Legal Business Name): KELSEY J KOZLOWSKI LCP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2021
Last Update Date: 11/18/2021
Certification Date: 11/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N FAIRWAY DR STE 208
VERNON HILLS IL
60061-1803
US

IV. Provider business mailing address

208 N FAIRWAY DRIVE SUITE 208
VERNON HILLS IL
60061
US

V. Phone/Fax

Practice location:
  • Phone: 847-996-6666
  • Fax: 847-996-6665
Mailing address:
  • Phone: 847-996-6666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.017609
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: