Provider Demographics
NPI:1790133056
Name:KIRCH, LAYNE (LCSW)
Entity Type:Individual
Prefix:
First Name:LAYNE
Middle Name:
Last Name:KIRCH
Suffix:
Gender:M
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:PO BOX 1109
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-7109
Mailing Address - Country:US
Mailing Address - Phone:815-756-4875
Mailing Address - Fax:815-756-2944
Practice Address - Street 1:111 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1948
Practice Address - Country:US
Practice Address - Phone:630-587-3777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490246881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL474579189001Medicaid