Provider Demographics
NPI:1427388115
Name:NOLEN, KELLY (LCSW, TYPE 73)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:NOLEN
Suffix:
Gender:F
Credentials:LCSW, TYPE 73
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6521 BRIDLE PATH DR
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-3343
Mailing Address - Country:US
Mailing Address - Phone:708-833-7841
Mailing Address - Fax:
Practice Address - Street 1:132 E 79TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-2302
Practice Address - Country:US
Practice Address - Phone:773-487-0515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-03
Last Update Date:2010-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490104741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical