Provider Demographics
NPI:1275609059
Name:HUSTON, KATHLEEN R (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:R
Last Name:HUSTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-2614
Mailing Address - Country:US
Mailing Address - Phone:847-940-0880
Mailing Address - Fax:847-940-0880
Practice Address - Street 1:833 MONROE ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-2614
Practice Address - Country:US
Practice Address - Phone:847-940-0880
Practice Address - Fax:847-940-0880
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
210964Medicare ID - Type Unspecified