Provider Demographics
NPI:1417516824
Name:COMBS, KELLY (PSYD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:COMBS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 W WASHINGTON ST STE 1000
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3041
Mailing Address - Country:US
Mailing Address - Phone:248-765-7127
Mailing Address - Fax:
Practice Address - Street 1:69 W WASHINGTON ST STE 1000
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3041
Practice Address - Country:US
Practice Address - Phone:248-765-7127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007792103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical