Provider Demographics
NPI:1376318972
Name:KIMBROUGH, LORYN CHAS (LCPC)
Entity Type:Individual
Prefix:
First Name:LORYN
Middle Name:CHAS
Last Name:KIMBROUGH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18300 S HALSTED ST STE B-1
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60425-1046
Mailing Address - Country:US
Mailing Address - Phone:708-925-4321
Mailing Address - Fax:
Practice Address - Street 1:321 GRAHAM HALL
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-3078
Practice Address - Country:US
Practice Address - Phone:708-925-4321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-24
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.015012101YP2500X, 101Y00000X, 106H00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty