Provider Demographics
NPI:1326211947
Name:HIRD, KELLY (LCP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HIRD
Suffix:
Gender:F
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 N VINE ST
Mailing Address - Street 2:UNIT 201D
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-1652
Mailing Address - Country:US
Mailing Address - Phone:815-768-9688
Mailing Address - Fax:815-717-7256
Practice Address - Street 1:305 N VINE ST
Practice Address - Street 2:UNIT 201D
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-1652
Practice Address - Country:US
Practice Address - Phone:815-768-9688
Practice Address - Fax:815-717-7256
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-03
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IL071007734103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health