Provider Demographics
NPI:1477078921
Name:FATTEN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FATTEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2635 W THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3412
Mailing Address - Country:US
Mailing Address - Phone:1630-464-0344
Mailing Address - Fax:
Practice Address - Street 1:2310 W ROOSEVELT RD FL 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1131
Practice Address - Country:US
Practice Address - Phone:312-655-7991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-06
Last Update Date:2017-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker