MEDICARE: DR. KENNETH A GLEAVES PH.D., LCPC, NCACI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	2812	IL
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	006460	VA
3	101YP2500X	Professional Counselor	180001207	IL

General Provider Information

NPI Number	:	1609984764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH A GLEAVES PH.D., LCPC, NCACI

Provider Business Mailing Address
First Line	:	3450 W MAPLE ST RM 200
Second Line	:
City	:	EVERGREEN PARK
State	:	IL
Zip	:	60805-3043
Country	:	US
Telephone Number	:	708-422-2885
Fax Number	:	708-422-7161

Provider Business Practice Location Address
First Line	:	3450 W MAPLE ST RM 200
Second Line	:
City	:	EVERGREEN PARK
State	:	IL
Zip	:	60805-3043
Country	:	US
Telephone Number	:	708-422-2885
Fax Number	:	708-422-7161

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	06/20/2025

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