=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356647721
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAREN JEAN KEWLEY LCPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2011
-----------------------------------------------------
Last Update Date | 02/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5016 N UNIVERSITY ST STE 109
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61614-4763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-573-4834
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 710 BITTERSWEET AVE
-----------------------------------------------------
City | GERMANTOWN HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61548-8658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-922-1145
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 180007688
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------