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General NPI Number Information
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NPI Number | 1528536356
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Entity Type | Organization
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Legal Business Name | KELLEY OLDHAM COUNSELING GROUP
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Dates
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Enumeration Date | 11/09/2018
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Last Update Date | 11/09/2018
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Provider Practice Location Address
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Address Line | 4201 N DAMEN AVE
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City | CHICAGO
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State | IL
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Zip | 60618-3021
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Country | US
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Telephone | 847-208-7873
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Fax |
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Provider Business Mailing Address
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Address Line | 2109 W MONTROSE AVE
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City | CHICAGO
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State | IL
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Zip | 60618-1719
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Country | US
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Telephone | 847-208-7873
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Fax |
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Authorized Official
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Title or Position | THERAPIST/OWNER
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Name | MRS. KELLEY OLDHAM
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Credential | LCPC
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Telephone | 847-208-7873
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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 |
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License Number State |
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