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General NPI Number Information
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NPI Number | 1831585751
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Entity Type | Organization
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Legal Business Name | KELLY KAZUKAUSKAS CLINICAL PROFESSIONAL COUNSELING, LLC
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Dates
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Enumeration Date | 04/07/2015
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Last Update Date | 04/07/2015
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Provider Practice Location Address
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Address Line | 3105 S DEARBORN ST STE 246A
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City | CHICAGO
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State | IL
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Zip | 60616-2852
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Country | US
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Telephone | 312-567-3506
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Fax |
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Provider Business Mailing Address
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Address Line | 13602 S TARA DR
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City | HOMER GLEN
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State | IL
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Zip | 60491-9172
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Country | US
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Telephone | 312-933-1162
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. KELLY KAZUKAUSKAS
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Credential | PH.D., LCPC, CRC
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Telephone | 312-933-1162
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 180.008591
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180.008591
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License Number State | IL
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