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General NPI Number Information
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NPI Number | 1922912468
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Entity Type | Individual
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Provider Name | KELLY BAKER TYSON
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Gender | Female
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Dates
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Enumeration Date | 10/01/2026
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Last Update Date | 10/01/2026
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Provider Practice Location Address
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Address Line | 175 E HAWTHORN PKWY STE 155
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City | VERNON HILLS
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State | IL
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Zip | 60061-1493
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Country | US
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Telephone | 847-847-4977
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Fax |
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Provider Business Mailing Address
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Address Line | 1037 SHAMBLISS CT
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City | BUFFALO GROVE
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State | IL
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Zip | 60089-1247
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Country | US
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Telephone | 847-847-4977
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 178033381
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License Number State | IL
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