=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356222186
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY ANN RUNNINGEN LSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2025
-----------------------------------------------------
Last Update Date | 09/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 777 CENTRAL AVE STE 17
-----------------------------------------------------
City | HIGHLAND PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60035-3246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-441-5600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 777 CENTRAL AVE STE 17
-----------------------------------------------------
City | HIGHLAND PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60035-3246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-441-5600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 150.117557
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------