Provider Demographics
NPI:1689769119
Name:CORN, KATHY JO (MA, LCPC)
Entity Type:Individual
Prefix:MISS
First Name:KATHY
Middle Name:JO
Last Name:CORN
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 W. MAIN, SUITE 201 B
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220
Mailing Address - Country:US
Mailing Address - Phone:618-825-0051
Mailing Address - Fax:618-825-0051
Practice Address - Street 1:521 W. MAIN, SUITE 201 B
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220
Practice Address - Country:US
Practice Address - Phone:618-825-0051
Practice Address - Fax:618-825-0051
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-00091101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health