Provider Demographics
NPI:1508315557
Name:RICHTER, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RICHTER
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 1:16027 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-4028
Mailing Address - Country:US
Mailing Address - Phone:815-932-3823
Mailing Address - Fax:
Practice Address - Street 1:581 WILLIAM LATHAM DR
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2317
Practice Address - Country:US
Practice Address - Phone:815-932-3823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-30
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150,101968104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker