Provider Demographics
NPI:1578715165
Name:CANADA, KELLI ELIZABETH (LCSW, MSW)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:ELIZABETH
Last Name:CANADA
Suffix:
Gender:F
Credentials:LCSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 N. RACINE AVE
Mailing Address - Street 2:#3E
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607
Mailing Address - Country:US
Mailing Address - Phone:773-573-0846
Mailing Address - Fax:
Practice Address - Street 1:2750 N. RACINE AVE.
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614
Practice Address - Country:US
Practice Address - Phone:773-529-1200
Practice Address - Fax:773-296-6131
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0113581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical