Provider Demographics
NPI:1679846455
Name:GILMORE, KYLA MARIE (LCPC)
Entity Type:Individual
Prefix:MS
First Name:KYLA
Middle Name:MARIE
Last Name:GILMORE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1147
Mailing Address - Country:US
Mailing Address - Phone:312-925-8257
Mailing Address - Fax:
Practice Address - Street 1:1010 LAKE ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1147
Practice Address - Country:US
Practice Address - Phone:312-925-8257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-09
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007979101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional