Provider Demographics
NPI:1518631837
Name:KIENZLE, ELIZABETH KATHLEEN
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:KATHLEEN
Last Name:KIENZLE
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 1:413 BEDFORD LN
Mailing Address - Street 2:
Mailing Address - City:VOLO
Mailing Address - State:IL
Mailing Address - Zip Code:60073-8182
Mailing Address - Country:US
Mailing Address - Phone:847-504-9382
Mailing Address - Fax:
Practice Address - Street 1:413 BEDFORD LN
Practice Address - Street 2:
Practice Address - City:VOLO
Practice Address - State:IL
Practice Address - Zip Code:60073-8182
Practice Address - Country:US
Practice Address - Phone:847-504-9382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009749101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty