Provider Demographics
NPI:1447794763
Name:WYDRA, KELLY JEAN (LCPC, CADC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JEAN
Last Name:WYDRA
Suffix:
Gender:F
Credentials:LCPC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 RHODES LN
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-0341
Mailing Address - Country:US
Mailing Address - Phone:815-651-1983
Mailing Address - Fax:
Practice Address - Street 1:4923 MAIN ST
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-3654
Practice Address - Country:US
Practice Address - Phone:815-651-1983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007933101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor