Provider Demographics
NPI:1497495246
Name:VAN KOEVERING, KYLIE MARIE (LSW, CADC)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:MARIE
Last Name:VAN KOEVERING
Suffix:
Gender:F
Credentials:LSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2298 COUNTY LINE RD STE B
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-2561
Mailing Address - Country:US
Mailing Address - Phone:331-214-3792
Mailing Address - Fax:
Practice Address - Street 1:2216 W GIDDINGS ST UNIT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2002
Practice Address - Country:US
Practice Address - Phone:304-993-3036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.106532103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYV18-079-062Medicaid