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
State | License ID | Taxonomies |
---|---|---|
IL | 149.018710 | 1041C0700X |
IL | 150015189 | 104100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No | 104100000X | Behavioral Health & Social Service Providers | Social Worker |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | 3217639118001 | Medicaid |