=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508374521
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. KELLY WALSH ADAMIK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2018
-----------------------------------------------------
Last Update Date | 01/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9311 SHIELDS AVE
-----------------------------------------------------
City | BROOKFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60513-1825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-482-2430
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1050 W HUBBARD ST APT 1B
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60642-8384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | 1877048
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------