Provider Demographics
NPI:1477089290
Name:SIMPSON, KENNETH SR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:SIMPSON
Suffix:SR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4747 LINCOLN MALL DR STE 412
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-3821
Mailing Address - Country:US
Mailing Address - Phone:708-300-6977
Mailing Address - Fax:708-300-6978
Practice Address - Street 1:4747 LINCOLN MALL DR STE 412
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-3821
Practice Address - Country:US
Practice Address - Phone:708-300-6977
Practice Address - Fax:708-300-6978
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2022-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL23393101YA0400X
IL22083405300000X
IL149.0216241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1447089290Medicaid