Provider Demographics
NPI:1336664705
Name:CANADA, KELLI D (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KELLI
Middle Name:D
Last Name:CANADA
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 1:911 REMINGTON RD STE B
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4210
Mailing Address - Country:US
Mailing Address - Phone:217-234-3091
Mailing Address - Fax:217-543-2548
Practice Address - Street 1:911 REMINGTON RD STE B
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4210
Practice Address - Country:US
Practice Address - Phone:217-234-3091
Practice Address - Fax:217-543-2548
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490195061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical