Provider Demographics
NPI:1518064294
Name:PROVENZANO, KATHRYN ANNE MARIE (LCPC)
Entity Type:Individual
Prefix:MISS
First Name:KATHRYN
Middle Name:ANNE MARIE
Last Name:PROVENZANO
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 COUGAR TRL
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013-6057
Mailing Address - Country:US
Mailing Address - Phone:888-291-2538
Mailing Address - Fax:847-516-2510
Practice Address - Street 1:1100 COUGAR TRL
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:IL
Practice Address - Zip Code:60013-6057
Practice Address - Country:US
Practice Address - Phone:888-291-2538
Practice Address - Fax:847-516-2510
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
214685Medicare ID - Type Unspecified