Provider Demographics
NPI:1093098477
Name:PRUGH, KIMBERLY NICCOLE (LMFT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NICCOLE
Last Name:PRUGH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1961 W SUMMERDALE AVE
Mailing Address - Street 2:2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1040
Mailing Address - Country:US
Mailing Address - Phone:773-474-9082
Mailing Address - Fax:
Practice Address - Street 1:5225 OLD ORCHARD RD
Practice Address - Street 2:SUITE 37
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-4405
Practice Address - Country:US
Practice Address - Phone:773-474-9082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166.000945106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist