Provider Demographics
NPI:1114514932
Name:ZAVALA, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ZAVALA
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 1:3106 GUNDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3120
Mailing Address - Country:US
Mailing Address - Phone:708-539-9227
Mailing Address - Fax:
Practice Address - Street 1:137 N OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1344
Practice Address - Country:US
Practice Address - Phone:708-539-9227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178014302101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional