Provider Demographics
NPI:1326422437
Name:WEITZMON, KENNETH (LCPC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:WEITZMON
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 S 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60155-2864
Mailing Address - Country:US
Mailing Address - Phone:630-801-2633
Mailing Address - Fax:630-801-2525
Practice Address - Street 1:1325 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-1449
Practice Address - Country:US
Practice Address - Phone:630-801-2633
Practice Address - Fax:630-801-2525
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180008844101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health