Provider Demographics
NPI:1467174540
Name:RISTAU, KELLY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:RISTAU
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:PO BOX 4555
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60567-4555
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 N MARION ST STE 313
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1023
Practice Address - Country:US
Practice Address - Phone:708-320-1441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0005262103TC0700X, 103TF0200X
IL071.009856103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic