Provider Demographics
NPI:1366508459
Name:KELLY-KLEIN, ELIZABETH (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:
Last Name:KELLY-KLEIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:VALICENTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:570 SHERIDAN SQ
Mailing Address - Street 2:#1
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-4762
Mailing Address - Country:US
Mailing Address - Phone:847-733-0829
Mailing Address - Fax:847-733-0826
Practice Address - Street 1:6650 N NORTHWEST HWY
Practice Address - Street 2:SUITE 201
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-1307
Practice Address - Country:US
Practice Address - Phone:773-633-0795
Practice Address - Fax:847-733-0826
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-31
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
202553Medicare ID - Type Unspecified