Provider Demographics
NPI:1255649349
Name:GOTTRICH, KAY A (LCPC)
Entity Type:Individual
Prefix:
First Name:KAY
Middle Name:A
Last Name:GOTTRICH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 S DURKIN DR STE 101A
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-8903
Mailing Address - Country:US
Mailing Address - Phone:217-572-1617
Mailing Address - Fax:217-303-8063
Practice Address - Street 1:975 S DURKIN DR STE 101A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-8903
Practice Address - Country:US
Practice Address - Phone:217-572-1617
Practice Address - Fax:217-303-8063
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-22
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004119101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional