Provider Demographics
NPI:1518600592
Name:RENNELS, KELLY (LSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RENNELS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 TUXEDO LN
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013-1714
Mailing Address - Country:US
Mailing Address - Phone:847-721-0172
Mailing Address - Fax:
Practice Address - Street 1:111 LIONS DR STE 210
Practice Address - Street 2:
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-3175
Practice Address - Country:US
Practice Address - Phone:847-865-4125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150107416104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker