Provider Demographics
NPI:1750835716
Name:VATIANOU, KELLY ANN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:VATIANOU
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 S MAIN ST
Mailing Address - Street 2:#B
Mailing Address - City:SUGAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60554-5023
Mailing Address - Country:US
Mailing Address - Phone:630-466-8657
Mailing Address - Fax:
Practice Address - Street 1:76 S MAIN ST
Practice Address - Street 2:#B
Practice Address - City:SUGAR GROVE
Practice Address - State:IL
Practice Address - Zip Code:60554-5023
Practice Address - Country:US
Practice Address - Phone:630-466-8657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL15009806104100000X
IL1490182871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker