Provider Demographics
NPI:1609984764
Name:GLEAVES, KENNETH A (PHD, LCPC, NCACI)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:GLEAVES
Suffix:
Gender:M
Credentials:PHD, LCPC, NCACI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 W MAPLE ST RM 200
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-3043
Mailing Address - Country:US
Mailing Address - Phone:708-422-2885
Mailing Address - Fax:708-422-7161
Practice Address - Street 1:3450 W MAPLE ST RM 200
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-3043
Practice Address - Country:US
Practice Address - Phone:708-422-2885
Practice Address - Fax:708-422-7161
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2812101YA0400X
VA006460101YA0400X
IL180001207101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)