Provider Demographics
NPI:1245787506
Name:TYE, CAROLINE KELLY (LCPC, ATR-BC)
Entity Type:Individual
Prefix:MRS
First Name:CAROLINE
Middle Name:KELLY
Last Name:TYE
Suffix:
Gender:F
Credentials:LCPC, ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 SEWARD ST
Mailing Address - Street 2:APT #3
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-5321
Mailing Address - Country:US
Mailing Address - Phone:847-651-8643
Mailing Address - Fax:
Practice Address - Street 1:2630 W FLETCHER ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-7110
Practice Address - Country:US
Practice Address - Phone:847-651-8643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-04
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL16-069221700000X
IL178012176101YP2500X
IL180011239101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist