Provider Demographics
NPI:1396178646
Name:PARMELEE, KYLE WADE (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:WADE
Last Name:PARMELEE
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 S MILWAUKEE AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3758
Mailing Address - Country:US
Mailing Address - Phone:847-367-5991
Mailing Address - Fax:847-367-5997
Practice Address - Street 1:1113 S MILWAUKEE AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3758
Practice Address - Country:US
Practice Address - Phone:847-367-5991
Practice Address - Fax:847-367-5997
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0187101041C0700X
IL150015189104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3217639118001Medicaid