Provider Demographics
NPI:1083964381
Name:BARRY, KATHERINE ROSE KENNEDY (MA)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:ROSE KENNEDY
Last Name:BARRY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:ROSE
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1104 W MONTANA ST
Mailing Address - Street 2:2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2221
Mailing Address - Country:US
Mailing Address - Phone:608-295-2830
Mailing Address - Fax:
Practice Address - Street 1:3504 COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1821
Practice Address - Country:US
Practice Address - Phone:847-272-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.008171101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health