Provider Demographics
NPI:1598784431
Name:KOSTOCK, KATHLEEN M (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:KOSTOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37512 N NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BEACH PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60087-2345
Mailing Address - Country:US
Mailing Address - Phone:312-590-8801
Mailing Address - Fax:
Practice Address - Street 1:37512 N NORTH AVE
Practice Address - Street 2:
Practice Address - City:BEACH PARK
Practice Address - State:IL
Practice Address - Zip Code:60087-2345
Practice Address - Country:US
Practice Address - Phone:312-590-8801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490011721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR97480Medicare UPIN
IL149-001172`Medicaid
IL929620Medicare ID - Type Unspecified