Provider Demographics
NPI:1750689949
Name:KELL, MICHAEL EDWARD (RN, LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:KELL
Suffix:
Gender:M
Credentials:RN, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2737 W LUNT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-3005
Mailing Address - Country:US
Mailing Address - Phone:773-973-2126
Mailing Address - Fax:773-537-3466
Practice Address - Street 1:6808 N WAYNE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-3718
Practice Address - Country:US
Practice Address - Phone:773-537-3615
Practice Address - Fax:773-537-3466
Is Sole Proprietor?:No
Enumeration Date:2011-03-11
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0115231041C0700X
IL041.173569163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical