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General NPI Number Information
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NPI Number | 1265735120
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Entity Type | Individual
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Provider Name | KENNETH LOUIS DALLA COSTA LCPC
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Gender | Male
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Dates
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Enumeration Date | 12/15/2010
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 15363 TULIP CT
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City | ORLAND PARK
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State | IL
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Zip | 60462-5024
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Country | US
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Telephone | 847-772-9289
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Fax |
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Provider Business Mailing Address
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Address Line | 13701 LAUERMAN ST 38
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City | CEDAR LAKE
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State | IN
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Zip | 46303-9292
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Country | US
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Telephone | 847-772-9289
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180005602
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License Number State | IL
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