Provider Demographics
NPI:1528536356
Name:KELLEY OLDHAM COUNSELING GROUP
Entity Type:Organization
Organization Name:KELLEY OLDHAM COUNSELING GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:OLDHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:847-208-7873
Mailing Address - Street 1:2109 W MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-1719
Mailing Address - Country:US
Mailing Address - Phone:847-208-7873
Mailing Address - Fax:
Practice Address - Street 1:4201 N DAMEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-3021
Practice Address - Country:US
Practice Address - Phone:847-208-7873
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty