Provider Demographics
NPI:1235444589
Name:BUSZKIEWICZ, KELLY (LCSW, LCADC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BUSZKIEWICZ
Suffix:
Gender:F
Credentials:LCSW, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:4950 NORTON HEALTHCARE BLVD STE 305
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2849
Practice Address - Country:US
Practice Address - Phone:502-394-6440
Practice Address - Fax:502-394-6465
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-11
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY165364101YA0400X
KY2531711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100490080Medicaid