Provider Demographics
NPI:1710344940
Name:ST. JOHN, KATHY
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:ST. JOHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 WBOMBAY WAY
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60067-4875
Mailing Address - Country:US
Mailing Address - Phone:847-721-4244
Mailing Address - Fax:
Practice Address - Street 1:1011 W BOMBAY WAY
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067-4875
Practice Address - Country:US
Practice Address - Phone:847-721-4244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-19
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009795101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional