Provider Demographics
NPI:1457656068
Name:SAMPLE, KATHRYN MARY (LCPC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARY
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:MARY
Other - Last Name:NAKONECHNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12 HEALTH SERVICES DR
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-9637
Mailing Address - Country:US
Mailing Address - Phone:815-756-4875
Mailing Address - Fax:815-756-2944
Practice Address - Street 1:12 HEALTH SERVICES DR
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-9637
Practice Address - Country:US
Practice Address - Phone:815-756-4875
Practice Address - Fax:815-756-2944
Is Sole Proprietor?:No
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180007627101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional