Provider Demographics
NPI:1003051574
Name:BRANNICK, KEVIN JAMES (LPC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JAMES
Last Name:BRANNICK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-2012
Mailing Address - Country:US
Mailing Address - Phone:708-447-2468
Mailing Address - Fax:708-447-0043
Practice Address - Street 1:3200 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-2012
Practice Address - Country:US
Practice Address - Phone:708-447-2468
Practice Address - Fax:708-447-0043
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178002986101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional