Provider Demographics
NPI:1750634358
Name:PENDERGAST, KATHLEEN MARIE (LCPC)
Entity Type:Individual
Prefix:MISS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:PENDERGAST
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 1:1320 W ROSCOE ST # 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-1414
Mailing Address - Country:US
Mailing Address - Phone:574-261-7547
Mailing Address - Fax:
Practice Address - Street 1:2001 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647
Practice Address - Country:US
Practice Address - Phone:773-217-8834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-19
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007897101YP2500X
IL180007897101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional