Provider Demographics
NPI:1043605827
Name:BALK, KELLY JANE (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:JANE
Last Name:BALK
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 W DIVERSEY PKWY
Mailing Address - Street 2:UNIT 305
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1884
Mailing Address - Country:US
Mailing Address - Phone:608-412-0626
Mailing Address - Fax:
Practice Address - Street 1:333 N MICHIGAN AVE
Practice Address - Street 2:SUITE 1900
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-3901
Practice Address - Country:US
Practice Address - Phone:773-321-2761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.009051103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical