Healthcare Provider Details

I. General information

NPI: 1922912468
Provider Name (Legal Business Name): KELLY BAKER TYSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY BAKER

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 E HAWTHORN PKWY STE 155
VERNON HILLS IL
60061-1493
US

IV. Provider business mailing address

1037 SHAMBLISS CT
BUFFALO GROVE IL
60089-1247
US

V. Phone/Fax

Practice location:
  • Phone: 847-847-4977
  • Fax:
Mailing address:
  • Phone: 847-847-4977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178033381
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: