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General NPI Number Information
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NPI Number | 1619609096
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Entity Type | Individual
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Provider Name | KELLY LYNN LEMAIRE PHD
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Gender | Female
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Dates
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Enumeration Date | 06/25/2022
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Last Update Date | 06/25/2022
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Provider Practice Location Address
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Address Line | 4043 N RAVENSWOOD AVE STE 302
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City | CHICAGO
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State | IL
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Zip | 60613-5683
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Country | US
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Telephone | 630-277-9033
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Fax |
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Provider Business Mailing Address
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Address Line | 1831 W WARNER AVE APT 2
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City | CHICAGO
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State | IL
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Zip | 60613-1862
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Country | US
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Telephone | 574-514-2347
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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 | 103TH0100X
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Taxonomy Name | Health Service Psychologist
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License Number | 200043270
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 103TH0100X
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Taxonomy Name | Health Service Psychologist
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License Number | 5412
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071010781
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License Number State | IL
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