Provider Demographics
NPI:1114433463
Name:PHAN, KELLEY THUY-LY
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:THUY-LY
Last Name:PHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 E ERIE ST STE 1600
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3111
Mailing Address - Country:US
Mailing Address - Phone:312-695-6868
Mailing Address - Fax:312-695-2729
Practice Address - Street 1:259 E ERIE ST STE 1600
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3111
Practice Address - Country:US
Practice Address - Phone:312-695-6868
Practice Address - Fax:312-695-2729
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-22
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA071010616103TC0700X
IL071010616103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical