Provider Demographics
NPI:1679180194
Name:MCKINNEY, KIM ELLEN
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:ELLEN
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:ELLEN
Other - Last Name:RUETER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3938 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-2810
Mailing Address - Country:US
Mailing Address - Phone:312-399-0483
Mailing Address - Fax:
Practice Address - Street 1:125 WINDSOR DR STE 111&113
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1536
Practice Address - Country:US
Practice Address - Phone:630-728-1744
Practice Address - Fax:630-998-7029
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.021036101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional