Provider Demographics
NPI:1063654002
Name:CROSSMAN, KENNETH R (PHD(C))
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:CROSSMAN
Suffix:
Gender:M
Credentials:PHD(C)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 N OAK PARK AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1344
Mailing Address - Country:US
Mailing Address - Phone:708-386-9690
Mailing Address - Fax:
Practice Address - Street 1:137 N OAK PARK AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1344
Practice Address - Country:US
Practice Address - Phone:708-386-9690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-06
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-003154101YM0800X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health